Randolph_Well Abandonment_20231006 (5)

WELL ABANDONMENT RECORD rarlrncrnalUsc.ONLY:.
This faint can be used for sioale or multiple wills II
1.Well Contractor-Inrolvadon: WF LL ARANDQNIVIFNT DETAYC 5
Rich Lemire 7u,-Numhcr of ivel s licittg ul►enduneil: 1
welI6L*actorNo kite(or aallownefNtsoriallj abaulanbrguatl6nlifigherprapcny) rN' mirlople. JnlcrNar ur read-mrtar �ir;lJ► ve1Ls ONLY kNb the wane.
CYNI?(7trcfJiN1:GVrrrirlfJJIN)i7d1,,1+'if!ltOrsalmifi�-firm
2593A
7b.Approximate vialunle of water rictnuining in riell(B)NONE (guL)
NC\trr 1CosttradorCcilifdaidonNvivh r
SAEDACCO FOR WATT R SUPPLY IVFLI S ONLY:
Cdnvaiiy Naraa lc.Type 6f disinfectant used:CHLORINE
2.Wdt Construction Permit 4:, 7607-MSWLF-2015,
I L�r,ill,rlJplttvblc urldd2nrlfLr ii.i.Crwrlr.SJu:e;)°uhlriree.lrrjedturr,cde.J fflaroaiJ 7d.Atnottnt of disinfectstnl used'2 OZ
3.Wcl l ur(check:�r'cll use}:
NWuter Supply Weil: 7c,Sealing:rhateialsusetl(check;all iliac aiiply):
OAgricultitrll ❑Mtunicip:rlrPtiblic fji Ncat CcniCnt Gr6ltt ❑ Rcrdon9tc Ctiips or 11ellcts
130cotlicm at(Hr atinef Cacaling Supply) ❑Rct idetiti;ll Wvtcr Slippl}'(Single) L]Saud Cement GmuL, n �p Dry CL•ly
❑hidusuriaUCourmercial ❑liesideuial 1Vatcr Supply(shared) ❑CQncret+ Groin' `mo w,I._ ; t �Will Cuttin�y
❑Ini tiao ❑'Specialty Gruel ❑Gravel
Non-Water Supply Wcll: U BeMouite Slurry' O C T U U 2023 Cl Oiher(explain mAcr 7g)
DD149mliloring ❑Recovety
iujcctionWell: X For cacLtnbtt�tiiil ril2t�id'aiititir rsrticEi(ieaunt'af,ntdotcrialsused:
❑Aquifer Rccha pc OGriiundt}aicr RetiWiniion Neat Cem. 241b ,Wtr 144gal. Sand Cem.:lb ,Wtr•gal.
❑Atluifer Storage aid Rec:iwer' 134a11iaily Barrier
❑Aquifer Test ❑SloninvalerDrpiawge
Bentonite.:71b ,Wtr:gal.
❑E�perinteu(ni'Ci+rlutotogf pStibsidat>t�CorNml 7;;.Priio•ide a brief dcicriptian of the abandonment prr►eafurc:
❑Gcodienuat(Closed Loop} ClTmcer
TREMIE GROUTED FROM BOTTOM TO TOP.
®Geaa(henllal(Hc:itinJdCoalinH Retum} CrlOihcr.(ex lain under 7y,)
drDato weli(s).:ibandonctl: 8-21-2023
52.Well lacaiion:
GREAT RAKES LANDFILL PZA-3
Catflily/fhvh:rMum C•a:ilit%;1DI)ClOppli:ablc) $•CeiKi(Ii:itivia:
3597 Old Cedar Falls Rd, Randleman, 27317 � � .-pfi�wt�
9/6/2023
Physical Address.City,aiid Zip StcrLitnrvof t_.-iirierl We I Couirrinr or Nell O.w r Vale
RANDLEMAN 'fv signing 11)'&foriut, 11felvify cerdfy�dluid like-tre!!(SJ tins(taere)nbnndoned in
lawr>ly f rccl ldcraiCteiitlnuNo.(PIN) riec'orrlruee ndlh 15.4 4CW 02C,0JQ0 or 2C,6.200 r6e1!Carisdntcllbn Slnnikrrefs
erred dknt a cop),ofilds record lxxs beets,provded do dhe.tre!!on'dder.
Sb.f.ttit ide and Iaagituttr 1n ttcgrccslminuteslsccnnds or dccisn;il tlegrces:
(ifvvOl rMd,olm b0oitg'issnffickiA) 9.Site diagram or additional well detalls:
You.ntay'use thi back'of dais pdg8 to'provide additiotmL well site.det:iils or well
728567.76 R* 1777988.07 �Y dtbandonuteidde(aiLs. You map also:ulaclu>dditioutlpogesift►ec�ssare•
CONSTRUCTION DETAIL-OF WELLAS)REIN(:ABANDONED SURNtrTL#I.iNCTRUC.TIO�TC.
:tdrrith arir11 curaedriicM.1a nrtcwrdA-)JJ',ui o7lr37da.,FrJr mtidriple byettiuir 6-mel-n•rrtu mfpply
finds ONLY lfJiltThe some wtv cYtu firdurtt cute pintf. 10a. For All \WcLlc• Submit 1bL5 form viithin 30 dots of completion of foall
abandonmcnl to the following:
Division of Water Rmiurces,Information Pr6c0Mng.Unit,
.1617 Mail SeiMce Center,Ruleihfi,XC 27699-1617
6h.Total well.depot: 72
Wit.Fur inlccUott NVells: In addition to seating 11az fnrnt to ilia addn:ss lit l0a
6c.RomltoW diameter:8.25 abmty.also subutil one*y of this forin tt'idriu 30 days of completion of well
(tn•} abandon"'Mil In(he folld ivini:
Inosiou of�Yaler Risourres,iludcrground lujed(ou Control POgram.
QL Water tcvcl.bclow'ground surface- (ft:) iG3b Mail Scr iicc Ccntei•,Italcrg h,lt( 27699-1636
Gc.Outcrd casing length(iflmnwn): (ft.) 10c.iur Water Slimily& fnicctran M.11a: In addition to seriding The fora to
the address(esi above. also submit one copy of this.fbutl within 30 days of
completion of vt,rll abandonment to the'ctstmly health depatintent of[be county
6f.lnctea easinhrhiny tcnynh(if Laaawn): (ft.)
ti�hcrc aharrdonctt.
Y
Gg.Scm"lengt1it(if knou,ri): (W
Foriu GW-30 Nonh'Carollm Depaniticr)i of Environment ant Natural Resotiacs-Divislan of Water ltootucvs Revised August 2013
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