Wake_Well Abandonment_20231101

1VI1iLjL A1SA1'NLU1N1V1.L1N 1 KL',I.,V (I) For lmenial Use ONLY 1 .
I�,Well Contractor Ilnformation/: WELL,ABANDONMENT DETAILS
��`��,= K . 7a.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW,-,30 is needed. Indicate TOTAL.NUMBER of
wells abandoned: I!
NC Well Contractor Certification Number 7b.Approximate volume of wateIr remaining in w ,/✓ell(s): D __(gal.)
4<-1- b �, �� (, (_ c1�',Lc— FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.'fypc of disinfectant used: ,�_"Q VI.�'
_____
Z.Well Construction Permit d: 6 w —i I ' (
lirn ull apphe•ahle wdl con.ctrucnun pernri+S(i.e. MC,Cunnh:.Slate, rurione•e,etc.)r(7.•n,nrn 7 f
7t1.Amount of disinfectant used: —_ _•_ __
3•Well use(check well use): —�'---
''t ater Supply Well: 7e.Sealing materials used(check all that apply):
oAgricuttural ❑Municipal/Public ❑ Neat Cement Grout 0 Bentonite Chips or Pellets
C)Geothermal(Heating/Cooling Supply) eel' dential Water Supply(single) 0 Sand Cement Grout . E'fSy Clay
Dlndustrial/Coinntercial -- D Resident al Water Supply(shared) E2'oncrete Grout 0 Drill_Cuttings_
❑Irrigation —_--_.._.__.—. ❑ Specialty Grout 0 Gravel.
No„-Water Supply Well: Cl Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
!(njection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwrater Reniediation _LL6/ ,
;oAquifer Storage and Recovery ❑Salinity Banter RRs
,bAquiferTest CIStormwatcrDrainage __�11 eoN&4 3u \
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief'ticseription;of'the abandonment procedure:
❑Geothermal(Closed Loop) CITracer P �f/)(^e,,,,A t I q•�)/ ?a4 p (G.I' ,(Z
❑Geothermal(Heating/Cooling Return) — DOther(explain under 7g)�__ l `l�/`(J( I!Iv li✓ GJ�s f� 7 ltC%
2,11,0P OaT (,)47"a Liai Tfq du
4.Date well(s)abandoned: I O/X7` 23 3 7F14./ IT f} CL tv—
5a.Well location: iti „NV _ `' V r '"[r (<.,3 �..;: ni 5 ?� 1__—___.
i
'IIMS i-'bti�`� � - _ NOV J s 2023
Facility IDi!(ifapplicable) 8.Certification:
Facility/Owner Name — �I
. . 6717 01,...b Tyao gh___Suo Ay AgRy 6 •
Physical Address,City,and Zip
Signature of Certified Well Contractor or Well Owneit•`si �"`1 Date
flK---1.--` _ _ B •signing This,/orn+, l herehl1 certify that the well(s) was (were/ abandoned in
County Parcel Identification No.(PIN) accordance with 154 NC,IC 0.?C.0100 or 2C.0200 Well Construction Standards
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and that a copy o/this record has been provided so the well owner.
Sb.Latitude:anti longitude in degrees/minutes/seconds or decimal degrees: •
i (if well Site diagram or additional well� details:
field,one lac/long is sufficient)
,�,e You Way uh back ol'this paonal details or well
230.0 -N z67' 5` 7-------\W abandornmentse dtetaeils. You stay alsoge attachtoprov adideditionaladditi pages
,yell if necessiresary.
, CONSTRUCTION DETAILS OF A'ELLLSI BONG ABANDONED SWIMlII'TAlI151 itucrl(.)N5
dim,*well cnuStr«[•nun recnrd(,c)i/invrdohlr. I•iu•«nrinpl'nrprcauu or n rr Mel- ,tit r,uppl r rvelle
ONI.t'with the seam.consirialum(hundunn«nr,cancan A ub,rutrnrr/innr IOa, I'nr Alt Wells: Submit Otis form within 30 days of completion of hell
abandonment to the following:
. Ga.Well IDth:—_ _ — i
Division of Watcr'Resow'ecs,Information Processing Unit,
f 1617 Mail Service Center,Raleigh,NC 27699-1617
Gb.•Total well depth:_____61 ---(It.)
lOb. For Injection Wells: iln addition to sending the form to the address in 10a
' above, also suhmit one copy of this form within 30 days of completion of well
he.Borehole diameter:______J-�_D___Jim) abandonment to the li,llowitig:
i
Division tut Water Resources,Underground Injection Control Program,
Gd ___�.
,Water level below ground surface: 2 ----..(t•l•) 1636 Mail Service Center,Raleigh,NC 27699-I636
i
I Oc.For Water Snooty& Injection Wells: In addition to sending the form to the
Ge.Outer casing length(if known):T_____------
—__(It.) address(es)above,also submit one copy of this form within 30 clays of completion
of well abandonment to the county health department of the county where
1.
abandoned.
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GI'.Inner casing/tubing length(if known):�.�
-(I't.)
6g.Screen length(if known): -----------"(I•tJ
Rnvicrtl _)).2m h