Randolph_Well Abandonment_20231006 (13)

WELL ABANDONMENT RECORD FarlrflurmlU!cONLY:,
'This foini can lie used for single or multiple Wells' i
I.,Vcll.CantractQr Inrornaation: WFLi..ABANDONMENT DETAIt Rf"
Rich.Lemire 7a vtttalacr of trt lls beta{;alaandoactl: 1
\5'clfCotYeietorNanic ortc.11otsisr '^iSnfiaU iiba�ifaailm:x�[Ionlils8ici, ru n Kv. lrouli))ple. inlefMaP or rmi-mut, ° sirply irells ONLY will) M� sane
( y` P y) cxw>starer)i�t.m5r9�riinriruuzat,lYIU LyUP SNhi If 0 afurrn
2593A p t
7h.Appni10mate vhlumc of*Ater t>cmaining invicli(s) oNE ( )
N6�1°c1lGbnitaclarCcrtifiailiai Nit ntacr
SAEDACCo FORAVATE R SOPPLV WELLS ONLY..
i.
CAn.>pany.Nanir 7r Type 6fdisinfq-taut.used.,CHLORINE
2.Well'Coustruct€on Perut(t#:, 7607-MSWLF-2015,
1lstir/lrrt>t>1'�;rble itxtllmrurltti ii..t Ccur)rtit Srete;J arJilrrr.L;rc�Ioa„rlc:I PJfi:rut,J)
• 7d:Atnottnt of dislnfcctaut ttsLvl:2 oz
3.Well uqL(eheckwcll me):
•Water Supply\Veil: 7c.Scaling:matctiuls used(cliect;all that apply):
pAgriculltttvt 17141 okipal(Pitblic lyd NOtI Ccnicnt.Gtutgt Q 13cntoriitc Chips or Rilcts
t7Caeeathcunat(Hc:ilincfCpalino fii U[Gg OSupply)' ORcsidcutOlWaters�ipply(singlcl ❑SaudG^`it-t L')rr Cy
❑hiduslrialfCommercial 1311Wdential Water Supply(shared) ❑Concrete'(rout �r, [+brill Culiiugs
❑itri tioa O'Specigity Grnul Q C T 0. 2023 ❑;Gr%"!'
Ittm�4'atcr Siapph}Veil: CJ Bentotute•Slilay 0 Other(explain under 7g)
Mmunhodile ❑ltecofere Itt��;hti ^ i i's': N:ti .l:f .i
injection VVcll: if.For each material provide amount-ofmaterials ascil:
❑AguiferRCcli*c. 13Grpund)r4lerRcnti:ditttion Neat Cem.•241b ,Wtr•144gal Sand Cem.:lb ,Wtr•gal.
bALInifer StotaSe;uul E2ec'oven' ❑Safluitr,'Damer I
❑Aipi*rTesi ❑Slonnyfatcruminiigr . Bentonite.:71b ,Wtr:gal. ;
❑ExpetttitP n1a1 T��Irualo4v pSubsideia ,Cgttltul ?g,Provide a brief'it6crirtitin of the nhaudnnment prrtcivlure:
00c9diertnal(Ckscd-Loop) riTracer
®Geothemtal(HkntinlXooGnRRctum) ClOther(ex lainunder:7u)
TREMIE GROUTED FROM BOTTOMITO TOP.
4.Ibateweli(s).aliandoned, 8-23-2023
Si Wc0 tucutiian: f
GREAT OAKES LANDFILL PZA-10
Facitit}•lOnixrNaicc' r-t;.ilityl])tt�E'�p{11i:ablc) S.tCerlilZtaCitiit:
3597 Old Cedar Falls Rd, Randleman, 27317 •' _ � :-PJJ^nc�t'� 9/6/2023
Physical Adilmm.City:aud2ip SiJciliuoi�fi_.-=it➢cdlValCoutrrtntortVefl'C}+tnr p;ut
RANDLEMAN By signing ihis;forrn, 1 hemby cerhf'lkai 1he ireil(s) wq,,i(irere)ahmidonad in
Couisty Rarccl Iderdil'i-idDnNo.(PiN) 6ccmilcinve tt ilh MA jVC fC-0'C,0100 ur2C.0200'r)'eld Ciuisinietlun Stanckrrels
and that a cop),offibs record has bef i.p,o,i kd-(q the.ti•ell otmvr.-
Sb L,gtitttttcaridlongitutrin.ctcgrceslininutoslsccoudsordecinitilctclgrccs:• I.
(ifivell rV141,qin t:0oog is solm icui) 9.Site diagram or additional vv.ell detaRs:
You ua}i.ltse llie bd&'of this page to piovide_additiomal well site.detdils or well
728935.32 IS 1777171.19. �V :abandomitetti details: You they also attach aildilioual Ages if necessary.
CONSTRticribm mTAILS OF%VELUc;)D131Nt:ADANb0NED 8t1BMr17rA1„TNSTRMT1ONS
:titrxb u�p eartveirCitnra ivevrrlisJ•Ji m ailmrifa Pew Jnniripla inj ifein rir tpan•waiLT snppty
uW6ONLY v�tri)ilk st)nia rom.owcaweabrinehve:tcnt.ina ciao Sirtvtrit cvPr.Fuarc d0a For All Well • Submit II1LS font ttithin 30 day`s of completion of urll
6y %VCR Qltt.PZA-10 abandotamcnl to'tlto following;
Div'isiun-'qf�Wuter Resnnrcey,dnfotwation Pritt�.v➢nt;.Qnit,
6b:Totat tvell deplh: 68 (1t,} LGl7 Mlail Scivice Ccntci,Raleiwti;NC 27699-1617
t0b.F-k inleelinn Will- In addition-to sending the f4mi to the address In. 10a
6c Roreitolo dlantetei:8.25 (oat•y. above,atso submit ove copy of ibis fg m tt'itbiii'30 days.of comptelion of cell
ubatidotntieut to tlu,follo��'iaa ; i
I
Div'isiouof%icrResourccs,QpderLground lnjectlou Cont6l Pr6gratu,
ft!.Water level`bcbfn•gm and.curfacce {ft:) ioe'Mail Scrvicc Center,Ralcigh.Ml 276 971636
6c.Outer casing length'(tlllmown): (fW IOc.L'or-Water.�,ii nl j 4, iulestfau M-lls: In addition to-sending the fora to
the addr>ss(es) abode. also subniit one copy of this.Ibmi within 30 days of
compk6on of well abandmtmene to the count)'Health dcp aliucitt of the county
6C Inner easinWashiny;length(if Wu Wn): (ft) >,ulaero aliatldotycd,
6K.Scri"etn length(if known): (ft}
Foma G1Y=30 Nonh'Camtlm Dcp,n=p1 ofEnsimanient m-4 Niituml ResoturN-Division of ViaterA6oPtm:s! Retired Augusa 2011