Alamance_Well Abandonment_20231024

WELL ABANDONMENT RECORD
This fo.inican b used for siiikle a r mulliple Walls
1.Well iuofltraciorblronmqtiotu WELL ABANDONMENT DETAILK
Brian Ewing 7j,Number of ivcffis being abando led:
!(V. widt'jPM, Infed-fon i#� IWIJ-11vire sIq)lb. woffit ONLY will) the sane.
4240-B -.jyjrl C i�eform.
7b.Approxhimte vatnume of m4tcr m6niining in ij-rll(j)i
SAEDACCO FOR WATER SUPPLY NVELIS UlcLY.,
7c.Type fit jisinfertant Ond..
L Wel[Caustruction Pemlt 0:
7d;Amount of&Infect"t uw4l:
3.Welt u A,(4*dt it ell If 1 02
Water Supply well: 7c.Sealing Rhaterials-lised(6001411 that apply):
bA 12 Ncat Ccfucnt,G'ft M Hcmonft Cliips of Nllcts
Molk"nal(Hcafil W�Coolftlr- 13,Dty Clay
Sup,ply) ElPeWetithil Water Supply(single) P Sund.COitllt Grout
0 IndusirwtComincicial likesidentild Water Svppl},(showed) P cdnc.rt.:tdorout 13,Dfill Cnifinp'0'sNcijlt}GIPLIf 11,Gravel
AYa Nopter Supply Well-. b Bentonite ilurq 6dwr(exiihinund'er7g)
Injection well: X For each material selected above,pimide amomt of materials used:
PAquikr Rcelmra c* Minittfidwater Retn6din600 Neat Cem,:471b Wtr:3gal.! Sand Cem.:lb Wtr:gal.
pAquifcr Sionium milkaoveq, llsnlfiftity Dander
[]AipiiferTo sa
EANpethimlol Twhatilop V l:3Subsjdeik%,_Coi9tol Hw Wure-
7-,%Pmvidi 0 hriefdoc.rlpan of e abandonment p t
ObLotitennal.(Closed Loop) M.Tmcer
TREMIE GROUT-FROM BOTTOM TO SURFACE
OGeothcfmal(HeatingWootigy,Retum) 00ther(ex-olain under�m
E
4.:Date%VIjj, _,lband6ned: 10-6-23 2023
OCT )
Sa.Well lueation:
raciftAlivivrNairc rxilfty IDN(iNppikab1c) COMO. fl-ofi:
810 Deep Creek Church Rd. Burlington, NC 27217 MR n 10/11/2023
Physical Address.City;and Zip of C4,10110 1V On Dwe
—Alamance 91,signing ilsfiann, I hstOy cordf0 that 11w well(s) wq.v oyem qbmdmied in
COUL4 Awel 1&1d450tJ0nNo.(PIN) occonlancc irih Mf Mc 020.66 or 2C.0200 1.1,W1 Cohowcuoll Starl(4zrefs
and that aicope oltitip.r,,60rd'l:vsbec'ikprovieed(a'fire t+efi owner.
51i,Lati6ift and lriugltudc in(EmccAilouiests&oOds or d&in i A fLigmi,
iirivell figold"011L '9.Site diagram or additional well detaffs:
36.1230 You tuak use th.back:ofth�pdgl*to��,F60de'addffional liell s6'&Uls'or will
N 79,40421 0 1 , '' "'
'Vou�ina,V a6 afia,ch 6"6o,naf pages if 11=1:ssant
CONSTRUCTION.DETAILS 6F WELL(S)REJ N('.AHAMI 110N.ED, SURNITITAT,INSTRUCTIONS
Ift Far All Wetis- 'Submit thb; Conn within 30 dAV s of cdnqplction of well
&i.Well 164-mw-1 abohwoulum to the roljoiving;
Division of Water Resonirm,Inform ntion.Prow.AngVuit.
fibi-TotaliveH depth: 25 A) 1 d17 Mail genice eentc'r,ItAkillh'.NC' 2769.9-1617
—
10b.F-4 I"Iculan Wells: In addifiblujo sending jim,f6mu.to the-address In l0a
qbo+t-;also subinit otle��)py or ibis leor'.ni,widdh 30
(;e,Wrehold diameter:2 'dayg,6f,camlilemion of_%tll
abiridountent 16 tbcfi g,Qlhi�vin
Diris.ioiiofNVaterRi,5'urcm,Undei-gr6.uudhijedto"totier"OlPrdgratu,
6(l.NVitertev.cl,bctdwgmu6dsurf;ic6-� 10.49
_00 w4 mail C ecnl te].r,ItAlcigh.NC 27699-IG36
6c.Outer casing lcngft(it linown): 010 In-�idditionto&endia.-,the fomkto.
_ the pbove, also submit no copy of this fount Within 30 days of
Completion of nA abakdaninmi to the mun'lly ly-nith department of the conor
6r.Inner"minWtubin'.iength(if Imoun):
6g.Seri length(if known): —00
Non G%V40 Naalftamfim Depanurd af Environment and Natural Rcsouces;-Divislon of Wateritc.idnices Revised Augurs2W