Randolph_Well Abandonment_20231006 (4)

WELL ABANDONMENT RECORD rarIntntalUmONLY:. 4
This foist canbe used for single or multiple~sells i
1.Wcll.Cantractor Inronnittiotu WELL ABANDONMENT DETA➢L.`4
Rich Lemire 7a,vumher of%%ells Veiny;uhauduncil: 1
;YYelICautr'cIorNaute(or s«.Ilouatrl)crxatLail)ali�ufarihtgwo.H6m161 crynupersy) Fop t++ulnjks trlrrrtlae U) lNlrJ-YIYnCJ '31rI1f.U� wells ONLY with rl srsue
nnrismrcfrikvirlrmiil�Airnera6 leer+c�v?.snlv+nf r.°vie f+ern,
2593A
NC NIMI Coplridat-Uti tic don Niviber 7 b.Approximate volunhc of%Fate•twin lining;in ri'cll(.WONE
SAEDACCO FOR.WATER.SUPPINMUSONLY.
i
Gong utyNantc
7c T)-grc of disiafcctnrrt tiactl:.CHLORINE
2.Wetl Construction Permit#-., 7607-MSWLF-2015,
Lt31irl1 ulaplkvbl�"ttrlllerrrritr(%e.Crwrly,S1ate,1'arJlirre.hrjer?ior rle.l tfR'rtorerr 7d,Attionntof disinfecthtul usc4l"2 OZ
3.�1'tell use(check W611 me):
Water Supply\Yell: 7c.Scaling n►uterialsnsed(chccl;all that apply):
❑Agrictalttiral I]hinnieiparlrT'thblic N li€enter"`rtri7tP _❑ Bcmonitc Cfiioi or Pe
_. .> i
❑Gcothcrinnl(Hcatinrf Co4lina Supply} ❑Ito lidentittl Water Supply(singlc) El Sand Content Grbut�`-P L. i a jO,Dry CU'-
❑1ltdustriallcomnicrcial ❑Rmdential Water Supply(sh:trod) ❑t6ttcrete'Grout O T �, ❑ Ddll:Cltltings
❑Teri •tion ❑Sptcidlty Gnhnl CT 0 V Z023 ❑ Gravel
Non-N'ttcr5uppye-�Vcl[: 0 Hentonita(ut �7n l�r Other(explain under 7g)
ismonliorine ❑Rees%ety G;•Y=� %° 'vi
Injection NNcll: X For.each ulaterfll selected above;provide autottntof.nuttcrials ttsc(l:
❑ArjttifcrltccharQe ❑GritirndnalerRentediritiali Neat Cem.:241b ,Wtr•144gal. Sand Cem.•lb ,Wtr:_gal.
❑Arptifcr Storage and Recovcn ❑sal i►ity Darner
Bentonite.:71b Wtr:gal.
❑AgnffePTest, ❑SlomnvaterD�rrin:tga
❑Eyttsti1veu0I ❑Stibsirlrlx:e Cowin 7g,provide a brief description of the abandonment promduLe:
Odeo lt`rmal(Closed Loop) OTracer
TREMIE GROUTED FROM BOTTOM TO TOP.
�IGeotbemtal(irIcnEin&'CaoliuttRetum} ®Othcr:(explainonder 7t)
4.Date wcll(s).;ib;mdoncd: 8-22-2023
Sa-Well location:
GREAT OAKES LANDFILL PZA-4
racilitj(Oteticr Nturc rxility IDN 0fSFpkiblcl l3.CetK1fl�.tcioit:
3597 Old Cedar Falls Rd, Randleman, 27317 _ _- 9/6/2023
Physical Address,City,artd Zip 5irrcihircrdt_eCilit:d 1Vefl Cautrtttor or%V411(hvwir Dare
RANDLEMAN 1i1+siguing 1hLs fvin, 1 helvkv certdjy time 11w irell('s) was(were)ribmidoned tit
Carualy. Pared ldogirk itlaitNo.(11IN) t4vrdantc trill?I TA WC IC 02C.0100 or 2C.6200 iMvil Car isir tirdorr Pawkw6
and Drat a coppaflhis•record has been,provkhTd.(o the-ireN otvner
5b.Latitude and longitude in dcgkcsfatinutestsecondi or dceimt AL.g;recs:
(ifteeil reld,ottc 4ttllou tssnJlicoct l} 9,Sitediagram or additional well deta.lis•
You may-use tlk bacti of this page to provide:additional well site.det6ils orM ll
728874.37 1777973.98 kaudotintetude(ails. You fuay also autachaddldoualpages if trecrssatV.
CONs'rR11GTION DETAIL 4 hF WFLi_(S)BEJNG ABANDONED SLIUMITTAT.iNIS_TRUCTIONS.
Atiath it�-V tvirwrriekla'n'cYard(s)J)'ariallWr- ,Ierr mttfupte iigeE ioir rxr tmimiYrrer sufplj-
t vik ONLY with 11ry sn»ns cotL HUtteli0+rkt6atrrbr+nhetrt.i jrr ctttr srrittnit wee rUnq. Lpa; For All %Veils: Suhhnit 1hLs fornr within 30 dkVs of completion of e•cll
6ri.%VcH Ing:P2A-4 abandoomcnl to•thc following:
Division of Urater Resources
,•infgrmntion Prucu%iny;.Unit,
61t.Total%sell depth: 77 (Iy,) .1617 ALtil Service Center,Ralciy;h,NC 27699-1617
19b.E-pr Tnleetion Wells: In addition to sending;the ftarnh to the address.In l0a
6c.N3otrlwfe dianicter"a•25 (iu.} above;also submit one copy of this fonts hvithiu 30 toys.of cornptelion of util
:ibatidonnreW to the following;
I
6d.�Yatcr level bctoe gr ntrtid strrfacc� Division of Water Resou mes,Undcrx;'t uu ud iti jecilou Cotit r 6l Program,
t63(r Mail"icc Ccnie'r,Raleigh,XC 27699 1636
➢Oc,r'nr Waiter&,pl•&inicctlon DV 11s: Tit addition to sending the form to
Gc.l�utcr casing Icnr h(it lmnn n): (ft") the address(es) above: also submit bne copy of this.form With'itt 30 days of
completion of well abandonment to the counts lwnlih department of the courtly*
6L Inner easinWtubioy;ten}-tie(if Imawn): (ft.)
%%here abando»'
6g.Series length(if kno%sn):
Fornt Gttr-so Nonh`Caro(Im Depannxm of Pnrin7nnt nt m>j N aural Itesowecs-Dlvis[on of'Yarer R autn s ltevi ed August ZD t_'.