Randolph_Well Abandonment_20231006

WELL ABANDONMENT RECORD For ldmutiUscONLY: �
rMs.faun pit be used for singte.or nudiip[e wells
1.Well CoutratWr tnf r
ortuation: ` �� 3&fit.L ABAND41Nh1ENT DETAILS
II
Brian Ewing 7a,Kutnber of wt:lls being altaudoned:.1
Well C'otvranorNaaw(4rirelluureiikRdiLj[ a44% nin6xta, .onl/.ur'preticny) For n+trlopla Pnjrrfar a' awn-11 ej. 9irpp! . wells .ONLY wab A wne
e tierrfrcribY+ll�5J111'J'fNfrNt�7lr,ynr+etvr,sa+hrn tnri..for+n;
4240-B
NC IVdt Conlragdr Ccitifi,�lion NnitrSci
7b.Arptosimate vg.lnine of hater i in:tinin-in (g
SAEDACCO FOR NYATr4,R_S.UPPi,X wMLS ONLY:
Courpany Nam 7e.Typ of disinfectant eyed:
2.Well Coustruct[ou Peradt N:
,6g 41lipp110ble't ell p wnd&(7:.-i^+x+nn.stag,Yurlamv.Infe ifam.ettt ffkhown 7d.ArnounI of Ad ifi&daut used:
3.Wdt ear(eheLlcweu nee):
Water Supply Welt 7a Scaling inpiMals usc+l(chgcic all that apply):
pADricnitttctl • plvtitnicipal%E'ttbt[c. tR.Neat CcM*Q"t,C p sciuonitc Chips or Rlicts
00tcr ,
witn;d `(Hcatinr f Co9lit>p Slgtply) pE;csidtntin[Water S'tiDP�'LsirigiC) D Sand�entenl Gtnutr`,����:�z��^Y ,r�ry C(ay�
❑IndustriaMomnicrOil ❑Rcsideutitrl Water y-„ ❑COnCrete`Grout '" Vgq—D j1 Cut Iin
pPt}'Cshurcd)
❑Ini tear l7 Spec ialtp Gruui - OCT O �' 2�230 GratM1
Non-V►'aterSuppiy��c01; C]Bentoidle:5l`f[l PJ Oiber(e_vxplainunder7g)
'1l live
®hiouitoring. ❑ReL:otery. �. . +r ..
Injection Wclh 7f,For each material scQclteiGhb_b prat do soatit Of.ntatcrials used:
pAquiferltccha%e pGrauridriaferRentedLttidn Neat Cem.:471b ,Wtr:3gal.l Sand Cem.:lb ,Wtr:gal.
OAti"i Sionrge a Retrovety naulinity Barrier
13Aiptifer Tts1 ❑St6i metier Dniirfade
❑Evpeinitetitul Tixltut►[elgy []Subsidence Giittroi 7g.Provide a brief description of the abaudaument proectlune:
DGeothetmal(ClosedLoop) 1_1Teacer
tiemi from-the bottom to'surface
Mwifienuat(Heclim'CoolinaRemo ®O&,r.(explain under7 ).
4.Data n'cll(s).abtindancd: 9-6-23
I
Sa.Well tucad6u.. I
Tram Lumber Company
raci11WChvtvrNamc Cxilh,;1De(fapplimblg) $•Ccrli(Tcatioii:
485 Burney Rd,. Asheboro, NC 27205 Brian Ewe n 9/19/2023
Physical Addtcm;City;acid Zip 5iilirinR of Ctisti!tcd LVell'Coturrgcir 0,,r':fl givR r t7tUe
Randolph llt+atfmtr{g this frirnt,.i bereby cerryy,dhv the n•e11(s) was(trove)a8m+doned nr
Cocioty f-trcl ld}Wrbcat(oirNo..(PiNj accoirlanie inith 15 i'AUlC 0e,0100.or 2C.0200 hell Cvustivrliori slawk)rrls
and dral a copar of71rrs record hoN beery provided to tlee.ti ell owuen-
Sb.,1 ztittidc'and Buugitnile'in,to mcr lirilRateslsccnnds ar decim
(ir.Lil degrccs; '
scll ewht,are. 9.Site diagram or additioual uell.ticrnlis:
You mly use r1k ba&of this page to prowitle additional wel sits details of tirell
N W abaudowneni details:*You tuay also:.smelt adtlitioual pates if"necLssuty.
CONSTRUCTiON.DETAILS Ott WELL(Si'BEING ABANDONED &IAMiTTAL MSTRLTM. ONS
:trrntl+11Y"11 CYl2Y1rLC1(U11/L'LW[tr3+'tj Oi'o7lraG?c. l�c'v mu/nplr.rile�rii+re.vr rwn-uxttcr.wpplp '
10h ONLI(widt 11m call srdUtu2Wrefurm 10a; For All Welts: Submit use`s fotrn tiitltin 30 daY5 of completion of well
Ga Well m •TN1W-1 abandonmenttb'thc followlkir
Division of Water RcsouruA,Information Processing Unit;
6b.Total t►c(1 depth: 30.
1617 N1+iil Service Cchter,•Raleigii,hf'-27699-1617
(ft.)
10b.l'irr liticetlon_\4'rlls: hi addition to senditig the form to the address in l0a
(lu:)
abort,also subtnit one copy of dies forth tvidiiii 30 days of comptetion'of cell
6c 8orchole diameter,l
- ttbiitidoanteu4 to the fallowing: , ;
Divislou.of WUlcrResources;.iTudcrgtotruti'Lijrctfan Conitvl Prnsram,
6(L Water kvF l below groand;;rtrfaece (ft;) i636 Ntail Service:(cheer,Raleigh,hC 27699-1636
Gc..nutcrcasin ten ) 10c.RE Water 8unniv e&Lilation Wens: In addition to seodit revs the fomr_to
g o(if kmawtt ' ( ) the'address(es), 'e abo . also subrnif oite copy of tht faint within
30 days of
completion of►yell abandamnetu to!t6c county health'departntetd of the counts'
6G InnercasinWhiiiing Length(ifiasown): VW
svluro a(xtndonccl.
6g.Scr&a length(if Irnortn):10 (ft.)
Farm GtV-a0 Nonh Carotltn Depanurni of Pnciroeancnl aW Natural Resouxcs-INvisian of Waterltesl ems Revised A gun 2013
I
i
I

l :
WELL ABANDONII+IEN.T RECORD Far Ida-maUsdONLY'
't"IM fount e=ikbdi ukd for sitagteot`tntdtipte.tsmlls
T,Will Cdntractot tnfarniati0ni BELL ADAN60NMEN'C OtTA tM:S
Brian Ewing 7:a.Number of mclls lacing ahgndu cil:.l
SYcltt�or eracabrh°curs(4r aettu}a persginlly iti�n innlna raell.o>i Si vlli;r"priSiCuy y Rul erfdapk flyiw0jr cv, rxw=tihter sun16, ue1t3� .©VLY wifh flea •sae m
ztiAaeitrirctfai'm6rrudrnieurRu,�nrr rou s�+livr�t cateJform,
4240-B
FIC Well ContragorCcnif libtr Nitirrber
74.Appiokimsiteinlnmt ratiiat�rernaiuin Tnwcll(s}t
SAEDACCO FOR WATERSUPPL Y WELES ONI
Cant ury Nae+c. 7e.Tmk of disin f eciant n3ed: J,
2.well.construction Permit 11:
I13trr11nfplttttbteiiefFl:rrritti/iaCoagv.Si.ve 4HariGV_Ljezffw4,dYt: fu,uWre.
X.Amount.of.&-infectant usa.,
3.Well uk(hod:Wen use).
Water Supply Well:, Tc.Sealing iaiytciitilsitse+l(elaSct;all thaE apply):
Oftficadtt 6l: 171v4anicrp111PtlErlic 'L-v Y f. Gm4nite Chips:otPellets::6d'.N�lt Ccnreti(.u(�aou�"
f](irnthermM(Mcad!►��f Coaling Supply) f3Residcntrpt%Vater:$I ipply(inglcJ 17 Sraucl Ceniod C..P CIO,
❑batrrstriaUCoannrcrcial ❑Residential Wat€r Snpply,(sharcd) ❑.ConMt Grout O C T V ElDtill Meetings
❑Teti fion O"5pecitiltyGapttl O 2023"a Gravel
Nan-Watcr.5u(aply AA16: CI EettlOnite Sla�i t:?� ?r -s a 7 ittier Ec�Tlaiu under 7gj
®h9onitodng- �Rtx:at•en Crs•u�r'��:?tz
injection Nell: 7f.For each tuaterial selected above;proside atnount'of materials used:
gagriifer Recharge ❑Gru�ttndriater RernedLuion Neat,Cem.•471b. ,Wtr•3ga1.' Sand Cem.•1b ,Wtr•gal.
DAgttifci Siopgi and 110(wety 0SAinity Barrierr,
❑rlyirifer lest []5ttiinntvter 17r>iitiage
❑E rairrientnl Tee latialogv I7Subsldettc�Corittiil 7g,Providr:a li i:f iliscriptiou'af the abaitdonmrent pracidure:
t7Geoihemral(CiosedImp) Cttm r-
tremi. from the bottom toi'surface
.C3C=themial(Heatiom''Cooling Remm) C30tltcrlimplain under-72).
P.
t,Elatkwell(s).abafndoncd 976-23
S&L Well totititin:
Tram Lumber company
FAotlUyir,rrtprNtum: FadlitViDN(fapplicablc) $:_cettiittcation:
485.Burney Rd, Asheboro, NC 27205 Brian Ewing. 9/19/2023
Physical Address;Cuy;slid gig Stgrirlrrc�arCectire+t Welt Cadr s+rcrr 4r;r.'dl fli�'rnr p qe
Randolph Ili;sefrrit�g this fcia�m,.f IrenBy`certrfy.thnt the ttyllfsj 9,qs(trerg)a8andwied he
Cauuij lY.=0 ldw i&Vaft No.(PIN) avvq tkutes with 154'X01C it2 L ;p1OO.ur X-0204 Veit C<uis7ruufori.aeirickrrds
and 71ra1,n 6ep3�at&1.r a ecurd Ims be'to provided to tlre.frell or;firer.•
Sb._L��ttihidcandlangtr�aic"in.de�cs"timfttutes/sccbndsordcciitt,•il'dcf�rces:
(&&ell O&W,ora�1,�rguty is$nt *111) 9.Sito diagram Or addltloaat�rlt ilct tlis:
You." ,ttse the hoc}:of tWs' pa o to'proti,ldc,-additiotial well.sits delails:oi well
N iY aliandoinuetil de`
ails You tua�'�I�o;istuclt adilitio►tul pales if teeccn_
(.YINSTRuL-noN,nETA1L5 oy WELL(3b"ttpINC.ABAND4}NRD :kjMjE TTAL TNSTRLiCTT0
:t11r7d'e Nrll eyrriylYuelreutn!twill;J'!j aiic7lraGF� �Iiir neultlplc ii�e�irirLe.rrr"raan•nxrhr sttpplj�
u efts ONLY.ri 11h.t1 aysre a oxsirm fdmNar r rrrhyrri tall,r we eun aibieit w�iFiim 1Q;p:•Far All Vcltc: Submit 11i S;fatm Within 30 d -S of i ompletian of titirll
6a.Wait M#:TMN-3
16tandtinrltcitt to the'f'ollattiin
Divigi6n of Water Resources,Information Processing Unit,
1617 Mail Service Ceuta,Ralcegh,NC 276/91617
6b.Total well.depth: 30 (ft}
101t.Far_iittectiain wells: Ht additibu to sending tbcf6nu to thi adduess in l0a
Gc.ftoechole diametet.1 (In;} abut e:Am stibinit.one copy.of This faun tsithiit 30 daays of completion,of well
:lbuodonnrertt td the,falloasittg_
Gtl.Natcr lcrel..helaie grotencl stiefaec�• (fQ:} Divisiott;of.Wntcr Rcsourecs,:T ntl rgruutid Itilea6n couitiil Pnograiu,
l636 A4ai1 Scn�ce Ccntri,Raleigh,hC.2i69-1636
Gc,.Qutcrcasin length lilt Fn P W:atcr Strnnl� .Cr hifrstf+in a� lls. in addition to sending the font to
gth(if(mown): . 00 the`.address(es),aboi i. also sufrutit one copy of this=fount %iittiin 30 days of
coMpletion of yell ahandomnent eo''the cbtmty hchtilr deparinrent of the county
Gf.inner 6sin;iltuhlnr teilydh(if twown): (ft.) whrie kninioncd,
fig Semis length(if latown):10
Form GeV-30 Nonh Cam11m 1lepaujoem of Endrosmant and Natural Resources-1}NMon of Water kesot=s Revised MAW 2013
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WELL ABANDONMENT RECORD r•Qtlmta>'MmONLY:,
Tttis fotinn can be used for single or tiwhip[e vMls
1.Well Contractor inforntatipn: WELL ARANWAIVIENT DETA A
Rich Lemire 7a,Num11cr of vvella being abandoned• 1
«'eft"C©rYcidothaure(ac�i�Ilotisa per�misll�allaiutflrilnnucUovldvlltcrprupeny) Fir rrnrldple tnfermir nr fain-nwrej. sup& kfvlls ONLY well; Me same
rfrrrvrrrrcUtNui�h�ariir++ir+riraf,,lvur carsrifvtuf rw�JFrvn
2593A
7b,Approximate valnm:of*atw rem ting in well(pi)ONE
N6\Ydl Coodractar�enifiarGau Kirmbcr �
sAEDACCo FOR NVATER SUPPLY WFLES ONLY.
coat>ltanp.Katno 7c.Type 6filhinfeLtant tried:CHLORINE
2.WfAl Coustructiou Pcrtuit 91, 7607-MSWLF-2015,
LL�rrdlUfrl>ttaublauNH,arrrritr(l.i..a"rnu?it SN1iN;YtrYJiirt'e,LiNrrfoi;Nlt'.f fJCuumrr 7d.Amoutllofdisinfectautrukd:2 OZ
3.WdI use(cliccl:we UIe).-
Water.Supply.Well: 7c.Scaling mtitetialsusctl-(ehccl alithat.apply):
pASr%ultttntl J7hltmic pal+T'trblic IM Nett Ccn cucG6!t la 13cittonitc.Chips of mIlets
OCicothcnMat Wiatce Snppl•(sine�lo} ❑ Sand Cenicrtt Gantt,r 's C• 1 XL
y t r- r'
❑lrxtustrial!(cirtttnercial ❑itesidentiatWitterSuppl}(shwed) ❑Coucra Grout �.. L-,. �/ rMl�tl Cltt6np
❑Irci •tiau •O'Spedaltg Gtout !+ 9' Gcttel
Kirin water Supply Wcll; b,&ntonite Sluay O C T 0 U 2Q2�Oilier(explain under 7g}
®A911111todhe ❑RCeot'en s c ^r :��r"3r rA;•�. i
Injcstion�Vc[k: 7f For.each tnat ei al el'eC(�isltu'r tt�vid�40tmtof mitt I als itsed:
❑Atjuifer[tccbargc ❑Ciruuitsh}alerRerited'uitibn Neat Cem.•241b ;Wtr:144gal.�. Sand Cem.:lb ,Wtr•gal.
❑Agtdfer Stonnye atxi Reawen, OS.tliuity hairier
Bentonite.:71b ,Wtr:gal.
❑Annifer Test OStomnv'atcr I7ntinuge —
❑EtperiretenleiTrxltnntoev ❑SuUsirletxc,.CurNtdl 7*Prtti•icic.a loelddescriptian of ihc.ab;tadonment nrtiicidure.
OGsodtennat(Closed-Loop) OTracer
Woothermal(ElcatiinglCoolinaReturn) 00dier(explain under 7a) TREMIE GROUTED FROM BOTTOM TO TOP.
3.DatcwcU(s).:thandnncd; 8-16-2023
5a.Well tocattim.,
GREAT OAKES LANDFILL -dW10R
r=11gfflwivrNupc raaiuylDn(ifuppiiwtitey �.�ertif�htioitt
3597 Old Cedar Falls.Rd,'Randleman 27317 _� 9/6/2023
Pitt-sical Addtess.City,and gig Srytitnw<dt rllc,i�Vt t Cnniclanl or lVcti C1?rrr r pate
RANDLEMAN Hy signing this foyer, I hemby certrfy that the trefl(sJ tars(were)ghandollad ix
taunty' ���{� farce]Idaralftes"OaNa.(PIN) ncvordinian-!1/rRM,bcfGOZC,f7fi7itpr3{'.U20t►fuel!f<;ri8lrttcriun$ltiniknrtls
r�(!l (/ rnridllrrrf acop)vflfilsnccurr�liasbiero. rintfetllo7hewell natter.
56.I adiude and longittrile in.dkinveslminuics/secuuds or d6chnal dorms.
iif.veli fatd,Otte L100jig is 1,4 4tv 9.Site dia_grain or additional well dctnils:
You may use the WC of dtis page to pro�'ide additional is'e11 site.dbils or vv*II
728517.87 1777389.16. V ;ibuudanutenttietails. 5'ou may oleo rdtaelt addiGontl pages if tteccssaty.
C-ON5'rRUC .10.X bH TA1LS 6V VVELL(S),BIJNC.ABAiNIHAED. S(I611tiTT,11,iNST UrT[ONS
:tflr+th vti:l!t�tir+.+•tiYTc7irua teevrrf,+s7•!f diull�filN. .F+'e�r mtiPttF�f�r+fNcticie ru'ra�n=nwlir s�ry�h
uelt-ONLY u•iPi1t The ati}tltarvnatxrxlewrr'arare�hsr+merit,�y�uc�nsiiturate*pfanrr' 10r. Far All �Vellst Submit thi_� forFu riithin 30 &aV5 of completion of cell
&L%yel➢[6g.OW1OR abtindonmcut to'thc following;
Dtt'isinn of Water Resenr0s,,Information Prucissing.Unit,
I617 Dfail Sen•ice Center,ILrlcit h.XC 27699-1617
6bi-Thtal well.deplb: 50
iUU.T+lr 1nlcWon Welts: In addition:ta 8cmdirtg the faint to t[te address to l0a
fc.lfo lta[e dtiiotetef:8..25/6 abow,aLm submit one copy or ibis foitri tvifli ii 30 da}'s of compleflon'of%vu
(u.) abatidounteu!to fhe,falJd>vin :
i
Divis.on.of Water Resource,underground hi jeetfou Cantrol Program,
6d.Water level h 1dw gr•oirnd surface:. (ft.} t636 Mail A *.cc Ccntcr,Raleigh,k 27699-1636
Outer c rein length rC lmoU tr); (fQ:} Il4c.i+nr 3V
.-iter, tnniv Tn g�fnn clip; In addition 16 mriding the faint-to
6c
fi I�( the addireess(esj above. also submit odi cop`' of this-form-Within 30 days of
cgmplcdon of uAl abandalmient to the c6ui ty health department of the county
6L!inner emitnl/tabiti j length(if Intayvu). (ft.) *ltcrc uhindoncd,
Gg Screcn Icng&(if linown):
Faint G%V-39 Naith Cacallm Depanitra l of Emironmix and Nat m i Resou.^ccs-Dlrlstanof 1VatcrR,2saurcas: Rcviscd Augu9 20 t_;

WELL A.BAND.O►NIVIENTRECORD FaT lr»dniti UzONLY;- `
This foini c5n be used or singl#or inullipte wells' k '
➢,welt.CnntrildbT Information: WELLARANDONRIE:NTDETAIL.S
Rich.Lemire 7a,Numller of imlls Using abandoued• l:
«TelfCot�ricfarh°cult(arucllon ertxtSoiialty:rlauoiddnbb�wFl.oa9d9rlr;rpiuperty) Ar nlrrJrrplc. Mtretliar ru runm1wrerI siy9ph' 1440& 01VLf wlrh 11, sa'Jre
'tYr11Yt7NGlNNr?Ar�rllfi�f!}IAJl71t•jYlrf LF1�13Ai'1JIlt on'JFJNJI�
2593A
NC R'c11 Coutractar Can ifiattim Niirtfer- 7U.AppmAmate volume of ieatu•tvrtrainittg lre ri cll(:1)NO (;i►t.)
� a
SAEDACCo F6R.Wt1TF.[t SUT@I.Y�V14I S i}IVT.j°:.
C4tivanyNinto 7c T�Irc(iEdisidti-tail r%cd:CHLORINE
2.�VL,11'caustttiction Permit#: 7607-MSWLF-2015
rim idl le 1'6%i11parwf6 94. Cau'rrn',51w;kariatie;brjerlfdg'at j'(fbmwir 7d rltriottnt of disinfectant uscd:'2 OZ
3.�Vd1 us+c"(chgcicwe"u.I0
Vater Supply AWL Vic.Sealing ltiutriials�ise+l(cltcct:all t li:tt unply):
pAStist.1141ta0 ph➢tuticiP tUPiibltc. CR Ncat Ci:r tent Grout la')3craoaite Chips of Pellets
C]GeoRlt'r nal Cahn CpallnR'S l}'} gRcSi¢atttittl tVatcr Su Ll Baru!C�ntertl Gt
(� o pplj(singlo) aJ A .,• .,
❑1ndusiriallComnicicini E311esidenti-d V;atrr Supply(shared) D Ccinuccte Grout D linll Ctttlitlgys
DGii lion 3'Speciult}Gr
• uu1 O C T 0 .V .2-0237`.Grtvel
lion 1Vatcr Suppty Wcll; CI.Bentonite Slutty 0 Other(explain under 7g)
®N➢anitoriitg l7R«ctiten' lmll'ar * i^n 'r•.F' ✓ ' vt
Injcetion�Vc[l: X For etch tuateritd sc-le tc'&A?-Qj eo%idc atnoutat 4f.ukutcrials twecl:
DAgoiferltecftarge DGrOtmditnterRcntediDtian Neat Cem,_•241b ,Wtr,:144ga1.'. Sand Cem.•lb ,Wtr:gal.
OAyuiferStotage and Rem ery DSalinity Barrier
Beirtonite.:71b ,Wtr:gal.
MriniferTesi OSlorninterLYrainagr -- -- - --
DEn'pef milettlol Tec:lmolcgjc. • M ibsldeire.,Coutral 7;r Prniidc.a Uricf.'discri�tioit of lUc.uliaridnnmcnt prrecetlun:
DGeodwnts;tl(Closed Loop. MTracer i,
TREMIE GROUTED FROM BOTTOM -TO TOP.
TOP.
DGeothemialfffeatiu 'Cooling Return) ClOthar(t. lainunder•7F)
a.Dateimtt ).:ibnnddned: 8-16-2023
5a.Well fuca0im.,
GREAT OAKES LANDFILL PZ-0,
Fucilit?'ICivirr•Nttirc Rkitity1Drl(1ftlppliQlblo) S•Cetliffta/suit:
3597 Old Cedar Falls Rd, Randleman, 27317' 9/6/2023
Physical Addrem.Cftc,acid Zip 5c cahim i�f 1 �lii i1 4VCll Comm.-tat OrAvell Ov"r Date
.RANDLEMAN T3}1:eiSJrir{y,rliLe farirt, 1 iiertfry cerliij'iltrrr the well fi)tyres ftrere)irbatd©ned in
Ctiaituy' Parcel Ident3f iiltinNo.(PIN) 66 v rhiaric n ifh 15.E New 02C,0100 ur;3G.6204 4%1i itrraratrtiarr smnikws'
" - anrllhrn'acetpyafttrist�ecorelhtu•beerapmvi�'cdfa7lte.toe11ouirer.�•
-Sli4 f.,atitude;ind long tw1c.in. or dcciti1.4.0grces:
(ifivell Card,Ora >atilOil 'iS s7rfrlCicut} 9,Situ diagraun or additional well'det:tllsp
Ymu nta}':use tli'e:bacic bf Utis page to,pro�t
de."addi6atL1E`iiU sitg.detoils or t��ell
727652.66. h 1778030.07. ��+ alauudonntetudetails. Youiuu}:tlso cltsidrl3G aim Cpogesiftteusatt'. -
(`_O NSTRIIC'I`IUWD4 TAILS OF WEIf t-fB>'Bg.iN('ARANii($NED SURNITr.W.TNS' UC.Tt.0 ,
:ltlW�r 51ie��GttinS•Ur}c7klrt-ticxlicif5l"i•]ui'iOtlA'J!C ,F1.v'ur��Pn(,iN urfettitiie.nr'1vJtl•n,tly&ujrp!!y .
u ulirs OVL➢ trlifi i}rr svn crue}�+t?+rer>w'aLbreehuarree�l.i°m.rbu siitvrrf!orrr itinrr 710a. Fat Ali-Wells Submit•this rarau xiithin 30 datVs of c8nipletion at urlt
ba `Nelfl Qi •Pz-63 abandpnmca tu'thc`fpiloit'ing:
• - Dir,isinnbf V1'utcr Rebriurr�,Infprm,iricir4 Prucc:s.�in�.Rnit,
6U Totat tell dcptli: 88 ,E 1617'Stail Scivice Ct:n(er,Ralci1eh. C 27699-161-7
YI)b.T r inlcct! n Wc11s: In additibn'to punting 1Wf6rm to the address 11.1103
Gc Bnveltali dinntctcr:8.25 a m-,uLsa sttlmtil'one copy of ibis Iron witfiiii 30 days of rotnpttuion of tc�ell
(u•) abunilonutent to the fn11att•irr3:
Di0sion of tiVater Resource's,Underground Iri jM(on Control Prdgratu,
fi.(l Water It Felbcltitr grottrid surfacac (fP:) 1i636 5iail Betties Ccntcc,Raleigh,NC 27604636
6c.Muter casing Ienrth(it Im-own); (ft') I0c•Ur.Warcr R mIjIly&Tul cr, flan tVellA In addition to&ending the form to
the address(esj above. also.subnut brie copy of this.form tdithin 30 dayg of -
cvrnptction-af Avel!abaeulamment to the lnunt}•Itrrfttt dePaittttefit a€the conrttp
6f.Irtticrwsint;JtetUin);tcn)'tlr(if lato�vn): ( ) tivhrre abandoned.
6n:Screen.length(if known):. (ft.)
Fornt G1Y-tu North Caroum D ponn-crb of Fnviroorncat aW Mautsl Resou TN-DlvLdanof Water Itemac's Revised August 2D t3
fI

WELL.ABAND.ONNIENT RECORD ForlmenaalU-mONLY:, f
This formtinbeused,k singlyarnmltipte�cclis'
1.Well-Cnnincctor_infnrnrntion: )Vfid,L.ABQZjI)6NNtENTDETAILSI '
Rich.Lemire 7w Number of wells being ailranduded• 1
l�TC1i. otxt(clort;anae(or�iclloti�ncrper3aii�tl}alli nino�s,tl.anl�llrcrlirapcety). F_ imadkole lggeriar tit; rvara iiwtee ArP�, aelb ONLY Willi lba swaie
cmevarrrcraiNa rti<„nr;Prnuu�rat,lrtrr aynrsrahaart tut�tlrrr6 '
2593A 7U.Apprent
NC�LrellConlTai iar CvnifadidarNriva6cr rntintate�'(tlnrne Elf lsuter rain in in rti•ell(a)NONE (g!p[)
fl
SAEDACCO FOR WATFiR SUPPLY WELLS t?It1I.Y:.
Gdaag�uq.Namc 7c,1�pc of dialnfectanq used:CHLORINE
.2.Nell Cunsttuctfou Pertutt tl:, 7607-MSWLF-2015;
Icsraillyvi�raJ}lei.kfliarmt�r0'.e:Cwarritsreii;d'.�iJtJrnee,lilrrlroiarrcffkimmrr 7d:Atnotttilofdlslnfectantttsed:2 02
3:wdt Use(ched:ricll use):
Water Supply Well:- 7e.Sealing:mutcrials•useri-(ch0k all that apply).
ClAari.-trlNmt 13Mun 1. 0 pal/Public., is Ncai clueot G61t ",' t a .-;la 13Fri(Rorta:Chir;s ofPellcts
17Grntltc rt(HcatinrJC pcallnrt S ty piicsitlenfi:tl lrJTtce Su to Sarin Centertt Gtutlt" �°ram. '' ,i rCJ) CLij'
o ) 1'P4'(single)
❑IndasiriAtContntercial 1711csidential'<VatcrSupply,(slnmd) O 6ticrefdGrudi OCT 0 nllCltHi,
G 2
❑Uii atimt np
13 Speciult}Grunt ravel .
NaalVntcr Supply Wall: Cl 8entowlte.51rtay Irib�,mn3,F^D ��^a Q €pplainunder7gl.
CffiMntitloeiitL; OReco4�en' G'�.{,,,`4f;•�'.:�
in jcctian�Vctlo- 7f.For each material selected above,provide antoanrof matcr'ials used:
lmquii&Recharge d3Gr0uH*jlerItetriediriE on Neat Cem.:241b ,Wtr:144gal. , Sand Cem.;lb ,Wtr:gal.
13AgtriCerStorage and,ke.iol'Lk l7S<1lihit$i t3arrier
❑Aituwr'fesi. C�SlontrieirterDnrin;lge Bentonite.:71b ,Wtr:gal. _
Etxppiatentil Trxliuningr. E3Sribsideixti CoiHtnl . 7g.Proi•ide a brief ilcscriptiun of the'Ap indonment prilii dire.
OGeodwrJnal(Clasod.Loop). 0-Tracer
TREMIE GROUTED FROM BOTTOM TO TOP..
�Geathemtal lH ttin Coolinr,Retum} 00(her( . laiamdcr.7lt)
4,Rat wclt(s):abandoned; 8-31.-2023
U Weil lueation:
GREAT OAKES LANDFILL PZ57D
l aeilitk;+4rixrTlumo Pin ility iDd+{t apptiablcl 8.Ceilifjc deii:
r�
3597 Old Cedar Falls Rd, Randleman, 27317 x .-�i"/�wC_f;- 9/6/2023
Fltrsieal Aitdre§,City;and Zip" Se+strhara of a iJ3cw11VLtl C�utneJor or tVCt�_fhsn r U,ue
RANDLEMAN . f3t?:vJ wing rJ5ls lQrJni, f lrer,°h},cerhjyWw Ow ire11{a)inns(Jrenz)gban loner/,is
coma(}' Nual ldetuit"ec 0941 o.(PIN) ricc'ortkinie a iilr 1,i�1 J� tC OZC,Qf 4Q'tir oC,4rQ(t R:e1f t uiis7ntriiuit S1atrifitizfs
nnrl J'krrfa crapt'af 16y record kirs been pri wiOcdto the-well owner.
Sb.LatOodeand longitude in.dcgrceslm'tnuicsA&oiids or dcciuMl degrees:.
(Ifn•e"AVU,Otte t;itilons 4'sniricrcutl 9..Sito diagram or additional Rcil dct.itlsc
You ua}'.we thi .back of Otis page.to'y'iovi&additional mlf s wiiztarls or will.729823.60, N 1778192.80. �_ V ,abundotmtean-&taik Yen tnai5 also aitaclt aif iiooal pages if ricc�san_
.CONSTRUCT.ION QFTA1LC 6N WFLLlS1,BEING ABANi QNED. S jMNit7"1'AT..fNST UC.Ti01iS.
:ttL•xh lairl�crJr:�•Jruclkm'rrcpreit'aJ JJ',aii6if�ift ,!?;r multy,lN Jnjrctirua ar lwn.nvru-�aryply , '�
n w1E�ONLY udrli atae av}yn�rTrmtra�riJar'r�t aaeehnrraLw m rnia SlrLmit cute fungi' t0a. Far-All Wells:• Submit this Corm riithin 30 days of cntnplction of well
6a �V.H®#.Pz57a - abaniionmcnt tn'tho'failotiving;
D10sion of Water Resources,Information Proelwdnu Unit,
6U:dotal tr'cll depth: 80 K(n,). Ido mlil Scivicc Ccater,ti rl¢i„ti,itC 27G99-ICit7
tob. as bke(W11 Wells:-fit additiou.ta.wi iqg tlte,fbtm to the ad&b Ss Jul_l0a
fc Bomeholedirtriteter:8.25/6 (iu,} abow.'also submit otiacopy of ihis fb6a widtiii 30 doys.of'coiciplelion oftcell
abandonuieut to tht:fallarti iql
Gti RratcrIcF'a bctot� rtrid sacf rco� {ft.) Diilsian of tVateettestJ"ec ibiiudcr}Iround tbjecttou to lrW Pr'ngraM'
1r t63fi N4ail Service CcnEcr;RafciPir,i1C 27499-106
do.Outer casin ken eftinor\n); - (ft;) 1k.Fnr\Vater Srmnh.&teiectlnn iVeil�r Ill addition to sending lbe fomtdo.
g ( the add¢ess(esi above. also.sub6iii one copy of this.toll within 30, dayt of `
coniptetion of%AI abandantnent to the c6lity laralth depaerinicid of the county
6L Inner wsinl Jtnhin"ten} iif C�aorvn): (ft)
ddterc abindonsd•
do,Scrcr:n length(if known): A) J
1i
Fount GIV-30 North Carotlm Dc(annrcm a1'Environment and Natumt Resourecs-Div islon of Pfater Resources, Rui ed August 2Ot3
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