Randolph_Well Abandonment_20230912

WELL ABANDONMENT Tkis-f-Oiniratti be fA�1VD()or single.oN1MENT RECORD Fat Inlamtl Use ONLY:
I.Watt Cnntr toter Infotmationt WELL ABANDONMENT Di'1`AIL.S
Stefan Smith 7a.Number dwells being abandoned: 13
MR Far nndnpte trl;ertfwr rie rnrl=tftitrrr supp:v frills .ONLY with t;re some
constawfie7ML'aboidahmint pa am.:intvndt cv efirat,
3576-A
7h.Appnii:iinate tulrinte at aratf•I remaining in ticil(s): (gal.)
NC Weli ConlragorCeitiftcttiotrNnni'ci a ' •
SAEDACCO FOR WATER SUPPLY WELt:S ONLY'.
Carnally Name. • 7e,Type Of disinfectant used:_. •
2.Wdt Construction Permit It:r r
Lai d1 trirpttiattrle ii�I$permit (Le.Ctiartir.&are.Kai iLuke.1, tiforr,,etc l 1f&amtrrr 7d.Atntunt of dillttfectant used:
3.Wdt user(cheek syell use): . •
Water Supply Well: 7e.Smiling nu;iterials used(sheet;:ill tirat apply):
17Agrictaltund 1:1MitnictpaliPtititfc. •CI-Nait CcrnetitGivu sS ,, �Eicni4nitc Chips or Pellets,
•
C]C�eattitcnnal(Elcatitr 't Molina Simply) pltcsidentytl Water Stipp),(Single) ❑ Sant Cement Gmut '�L.t r.:I Ettliocliy
D hutncttiaL&(:omntctciaf ❑Residential Water Supply'-(shared) Cl,Cauct.n Grout c C P 2 ❑Drill Cuttings •
❑lrtia ttion - 0 Specitdly Groat J` I . 2 0 Gravel
• Nctn WatcrSupply Well: 0 enteniteSlut , r� sn'pr g Olt ls ecplainunder 7g)o f :
f.
pfvloniiodng. ❑Rtruvei D"f'Gl a
injection Weil; if.For each material selected an ue, ide amount-of materials used:
❑Aquifer Recharge lGromiduaier Rentediation
oAiltrifri Storage and Rei oven' • DS,rlinity l3articr- •
❑AiluifetTesi • ❑StotyrrtvvlerDtteiringe Bentonite.:50 lbs per boringlb ,Wtr:gal.
❑CIeiiutental Tecitnolog DSitbsidefte Cotgtal ' 7g,Prnr tk a brief diseription of rite'abandonment pr'oeedure:
• iiGeotltetttat(Closed Loop) - . [1Ttacer
c 5eothetittal tTdeltinalr'Coolin&'Bement) ®Olin r(explainunder 7g). Pulled DPT tooling and,backfilled boring w/ hydrated
bentonite chips. i
3
.1,Date well s ahamloned: 8/9/23 I
Sa.Welt location:
I.
NCDOT Parcel .90 - - • , -
•
Faeilit<t'rt_11vtarNiutte FacilitylDrs tirapplicvblcl S,Cettiflc tiara..
4509 US-311' Sophia, NC 27350. . . pjfoLd
9/1/2023 •
Physical Address,City;aridZip ;~ irnstilled Well Contractni•or Well Oisrur Dal-
'
i
Randolph By!aping iI4.s Arm, f ltemhy eerti ,,that the sced(s}was(were)abandoned it!
Clorinij. Iarccl ld,:nliffeiii ottNo,(PIN) rrtarvrihttres uitlt ISA APIC 0,rCi',0iUl)or 2C.0200 Tr'ell CoDsiinr-tw i.Stenutimis
ant llrat a copy oflliis record hits'beeie pentided is/&elrelf owner.•
514.1-ltitudeand longitude in degrCcsliottnuteslseconds.ordecim;ut degrees .
(if.i•ell Vold,on tat/lanais irfficirra) 9.§ite diagram or-additional well:details:
You.tnay.are dr'e back of lists.pnge to provide additional well site details or well
•N .. •W ab itufoanieirt details.' You tuay alsa!iutncit:irltlitiana(p iges if necesstitv_•
•
CONSTRIIC ION.11FTAtd5(WINE:LEAS)!BBIN(:ABAND(1NED .t5VRMT1TALiNiSTRUCTiONS
:Wad/tn.d1 cori.Witctiart rtrxv'l()if aviiilab!L 1$v multiple i l O.40i err tvsa.uivei.xtippI1, ' '
Neck O1,4.1e.n•ttet the&Imre co.iattatoint/abolicioimaya.Iske Carr tirkiru't alw J6me Ma: For All Wells: Submit this form within 30 days of completion'or well •
6a,Welt ED#1.
IP-1 - IP-13 abandonmentto'thccfollowin� ':
Division of Water Rs sutures ,Inforanttiou-Processing Unite
1G171liiifScrticetenter,Raleigh,NC 27699-1617
6b.•Total well depth: 30 • (IL)
IOh.For Trtlectl(in Willi: In otlititiott to sending the foreu to the address is l0; •
•tic.Foteltoie dlauuctcr:2.25 �ti;y above_also submit one tope of this form twithiit 30'days of completion of.well
abtiudounremt to the following:
.Divisiott:of Water RiNonteas;Uttdergroulid hijeedYtun Ceentrul Pnigrant,
lid,Water level.below ground,sueface: (ft.) t636 Mail Senicercoter,Raleigh,NC 27699-1636
6c.Outer casing lcn lh(if known): • (ft.) the
or Water Srtnnly ark ln
.ileetliun Wells: In addition to sending the form to
the-address(es) abode. also sobit»t.one copy of this tbtitt within 30 days of
completion of well abandonment to the county health department of the county
61.tuner casing/tohi:mg length(if meows): (ft.) where al>redottcd, i '
I;
fiat.Screen length Of known): (ft.)
Fonts GW-30 Noah Caroltm Depanann1 of Ens:iroonicnt;all Natural Rcsouacs-Dh•ision of Water Rovoices Revised Aqua 26t3
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