Bladen_Well Abandonment_20231113

I .
WE LL ABANDONMENT RECORD Far tracrnul Use ONLY:. '
This form can be used ibrsing€e or multiple weds
I.Well Contr:icier Information: WELL ABANDONMENT DETAILS
Stefan Smith. 7a.Number of wells being obanduncd:1
Welt Corlrietorharne(or well oe>,nd pce5otiall3,'ab5)4oniao cell on lusil!ixprapeny) Far rtnrinple byectlon or rn a-tia(r 1 Sirppry' wells ONLY with the same
cMo ecti a ISAeiranneat pin can.sahnuf wrefi rm,
3576A
7b.Apprnrdmate cnlunre of water remaining in Well(s)1 • (gal.:)
NC Well ConlractorCeniftition Number 1
SAEDACCO FOR.WATER SUPPLY WELLS ONLY:
I.
Colopan)•.Nanie 7i.Type tit disinfectant used:-None
2.Well Construction Permit It:, Unknown, ,.
LW diNIplttuble wet parasite(i.e.Center.Stale.J ailii,.Ye.•Lrjertioi:,mess(Thrown 7d..Aniount of disinfectant used: ,
•
3.WM use(check w well use): '
VVater.Supply Well: • 7 e.Sealing materials used(chest;all that apple):
ElAgrieultural DMunicipit/Public • CI Neat Content.Grout 6d Rentonics Claps or Pellets •
. ❑Geothermal(HcatinrlCaoliti Supply) ORc:,ideuti:it.Water Supply(single) .Q Sancl Centeltt Grout ❑Day Clay
' 01ndn51rialICommcrcial ❑Resident►at Water Supply(shared) El Concn:(G Grout CI'Drill Cuttings
❑irrigation - -❑Specialty drool ❑.Grn'el
'Non-Water Supply Well: ' El.Bentoaite Slung - CI Oilier(explain under 7g)
IRManttoriitit ORecoven'
injection Welk - ' 7f For each material selected above,proside ttn(ount'of,materials used:
❑Aquifer Recharge . ❑Growidivater Itented€aeion i.
❑i.quifer Storage xixi Receveiy ❑Salinity Darner '
•
❑Aquifer Test • DSloiuimater D'rainnge — --- -ite-------b --.-,Itt algal.,__, . - . _-
❑Esprriuteuttil Technology ❑Subside) Coit(ml 7g.Provide a brief description of the abandonment procedure:
EGeottiermal(Closed Loop) ETracer .
®Geothermal iHeating/CoolingReturn) (3Othcr(expiainunder.7p) •
, N a,. .:v iz N it"v..; -
4.Datcwelt(s).:iband[ rcei: 10-18-23 U
NOV !,� 2023
5a.Well location: 1
1R,t Oii�•r+ctC.?1.S')�fi:i..lyv.'?':f,) ,lk�l'
Abandoned Station Highway 87 a..v'C:<n
Fat ility/thvncrMune FacilityWDM(iiapplicaiblc) 8 Certlfic3iial
8.072 Hwy 87 West.Dublin 28337 . 4 10/26/2023
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Plbysical Address.City.and Zip -Agin PrCeslitied Well Caneretur or Well Owls r .Date
Bladen 0026862- • • 11j+signing this fawn, 1 lfetiby cert fy,that the ire11(1.j-wrrs(here)abandoned in
County 1 Parcel ldLniiftealiniallo.(PIN) nirco dance ii all,15fi hCCAC 02C.,OiOO or 2C..0200 i('ell construction S/aniktrtls
and that a cnpy off1tis record l:us been provided(o lhe)4.e1 owner.-
5b.Latitude tintl longitude in degrceslntinutenslsccouds or dcciaiuit degrees:
(I two!!t`r k1;sic 41thrieig issellieten} 9.Site diagram or additional well details:
You,may use the bast:of this page to provide additional wolf site details or well
34.666725 , 78.730094
N VY :�audonnleiu details. You may'also attach additanal pages if rtec cssan.
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C(INSTRIICTiON DETAILS OF WELi JSl BEINCG ABANDONED SUBM1-1"1'A1.,INSTRUCTIONS- 1
.-Wuch MVP rvrastructnJu n+rurdfs)y'available. .Fw'nrilnpte injecrirnt or role-wale?supply i,
wells ONLY weir titer some rote U(rttoktho to;mecil.,imicrusubmituie3Jrrrc .10a.For Al! Wells: Submit'this fornr within 30 days of completion of well
6i.Well mill 1W - x abandonment to.the following: -
Divisinn of Water Resonree5,Inforrilation Processing Unit,
Gb.Total well depth: 11 tit.) • IG17 Mail Service Center,R alei„h,NC 27699-IGt7
10li.For Infection Wells: In additioit.to sending the Route the addtess In IOa
6e.t3ot�eftolc diameter:2 Om) abandonment
also subunit one cope of this forte within 30 days.of eompletioa of well
xbiandonuient to the.folleiwing: I
fd.Water Icvcl.bclnw ground surface:. 7 Vt.)
of Water-Resuurcis,Uruder'grouud Injectlun-Contr it Ptrogrnni, '
/636 Mail Scnicc Centel;Raleigh,NC 27'699-1636
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Ga Outer casiug1cnr Ir(if Imnn n): - .. (ft.) 10c.Far—ter Simply&Infection Wells: ht addition to sending the form to
the address(e) above: also submit one.copy of this foam Within 30 days of
compictioti of well abandonment to the a:aunty health depaunicrd of the county
6f.Inner easing/tubing length(if larown): (ft.)
where abandoned,
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6g.Screen length(if known): (ft.)
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Form GW=30 NontiCarolina Dcpanntcm ofEnt•Ironnicnt east Ninuiat Resoicecs-Division of WaterReaoulrcca Revi cd Angus(2013 •
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WELL ABANDONMENT RECORD For Internal Bse.ONLY..
.This font(can lie used for single o r multiple wells`'
I.WeflCnntracter information: WELL ABANDONMENT DETAILS,
Stefan Smith 7a.Number of:Neils being abandon)dI 1
Well oiin c1orName(Or wcltoc re7 .'rioinlS;ntiliit ini j oett 0a li Aterproperty) Ru rnduple Overton Le non-wa rI npply wells O,1LI' with the swne
cYNlmrr ediOnfrthair ionowi r,;Ivlo ckirr alhiliil I win?filrliI,
3576AI
NC Well Crrnlnrgor Cai1 illation Ntiulrcr lb.Apprnximate volume of water remaining in well(S)9 (gal,).
1 t.
•
SAEDACCO FO R.WATER.SUPPLY WELLS ONLY:.
Ceimp ny.Nanre • 7c.Type of disiufectarrt Used:None
2.Welt Construction Permit At:, Unknown, 1, .
.;LtaURulipliiiible:;ellparn ai'd.e.Cutlu{r,Siete.`nirimre.li;ecuit irete:1(fknown 7d•Amount Uf disinfectant.used:
3.Welty*(di'eckwell use): . • . •
WaterSupply Well: • 7e.Sealing matcrialstised(clrccic ali that apply): V .
❑A4ricuitttr.rl • ❑11Iunicipal/Pitblic ❑Neat Cement Grout • Ul Benionite Chirps or Pellets
❑Caro.dtermal(Heating/Coolint Supply) ❑Rcsidentiit Water Supply(Single) . ❑Saud Ceritent Gmut • ❑Dry Clay •
-
.❑ledtistrial(Commercinl ❑Residential WaterSupply,(shared) O Coucrrte Gniut ❑Drill Cuttings
❑irrigation V 0 Specialty Grout .❑Gravel
Nna 1Vater Supply Well: tJ Benlotiite Sluiry El Giber(explain under 7g)
ISMonhoring t7Recovei " . . .
injection WeU: 7f.For each tuaterial selected above,'ptbtide amountof.materials used:
❑Aquifer Recharge ❑Groundnater Renteduition
['Aquifer Stotngc aid Eieciavery ❑Salinity'Barrier _ •
❑Aquifer Test ❑Slonimater Drainage,
Bentonite.:81b ,Wtr:lgal. I
❑Eetimeulal Tcchhuloev ❑Stibsitfetrt Cot>;tn1 7g.Provide a brief description of the abandonment procedure:
°Geotherinal(Closed Loop) °Tracer
CiGeothemral( tinj/CoolingRetum) ClOthcr(explainundee7H) ¢-�''?�' {"'""` r Hca
4.;Datcwel(s):abandrincd: 10-18-23 . ;,NO V-I 2023
5a.Well tucotiirn: Ire rr r r i f.}�;;
Abandoned Station Highway 87 '
Li V i k. _•sv a
•
8.Certifieniiou•
-Facility/010erName FacilityIDaOfBpplicablc) i,
8072 Hwy .87 .West Dublin, 28337 ?""""' , l, 10/26/2023
Physical Addres,City.and Zip • 51._-Imo.,Certified Weil Contractor or Well Owmr .Pale
•
Bladen - 0026862 . By.vigning this Prot, 1 hereby certify't1tai the well(.)was(were)abandoned fit
County Parcel ltlesaitbcilian No.(PIN), iiecurrlauie with 1 Sit i'TGIC 02C,0100 or 3G.0200 frill)Construction Slatuktrie
• anddlrat a copy of this record h os barn jir ovided to lhe_we)!owner.• •
5b.Latitude and longitude in degrees/nrini(tcsfsccofds or decimal;degrees:. !,
Of welt field,orre 4it/lotb is sntrteicun) •9.Site diagram or additional well details: • .
You uiay.use the back of this page to`jlro%ide additional well site details Or Well
• .34.666725 . t\ • ' 78,730U94 W ;ibandonntertdetails. Yon truly alsoaii:icli additional pages if necessary_
CONS'CRIiC"CION DETAILS OF WELL(SI BEING ABANDONED 4tIRMTrPAT.INSTRUCTIONS. ' •
...nod/hell.construction recorai&'ij'ari J!oWc. .Per multiple injection or rwn•waler snppIr '
halls ONLY n ith IOe set(a cons rnrr/mr atuttnkninieul.jrm con submit.oire form. 1pp,For All Wells: •Submit'this fault Within 30 day`s of completion of well
Gsi Well W : 6 abandonment to the'following; I, V
' Division of Water Resnurcis,Information Prricessing.Unit,
6b.Total well depth: 7.5 • at) 1617 Mail Scnice Center,Raleigh.NC 27699-1617
lob.For linleclion Wells: In addition!to sending the form to the oddness to Igo
• above,also submit one copy of this form within 3b days of completion of well
6e.Borehole diartictcr:2
(lit) abaridoninent to the fbiltiwing:
Division of Water Begun rces,Undei%riittud injecttuu•Control'Pregratu,
Gd,Water level.below ground surface: Dry (ft.) 1636 IH:ril Sct •ice Centel".,Raleigh,NC 27699-IG36
Ga Outer eaciuglcngth'{rf)anoint(): (ft.) 10e.For Water Smithy.'Sr.iuiection Wells: In addition to sending the formic
the'address(es) above- also submit one copy of this fbmi within 3( days of -
campletion of well abandonment.to the county health department of the county
I
6f,Inner easing/tubing length(if,lerown): (ft.) Where abandoned,
6g.Screen length(if)mown): (ft.) •
Form OW-30 Nonlr Carolim Depanmcm of Environment an:I Natural Resources-Division ision of WatcrResources' Reeled Angus 20 l3
I

WELL ABANDONMENT RECORD For trnctit:IIUseONLY
This foint can lie used for single or multiple wells
+1.WeILCantractbr Information: WELL ABANDON1HEN1 DETAILS;
Stefan Smith 7a.Number of wells being abandon1ed1 1
Welt CortniCtorNanie(ors%clloweerper5gnallyahidaaing well oa liadterpropeny) For nnrfriple tnlertlar w rasa-iia}erl •;sitppfy wells O.YLr with N.w some
cottstrrrco''owhhorrdrl imete,,JOIN igur slim one lust,
3576A
NC Wog Contraeior Cat ifiattioo NJin�cr 7b.Approximate vilhrme at water j niaining in tsell(s)1 (gaL)
SAEDACCO FOR.WATER SUPPLY WELLS ONLY:
C9Inpany 1.anie 7e,Type nfdisinfcetant used:None .
2:Welt Construction Permit#:r Unknown,
Litt id1 ajrpik ble irell't'tenuity(i.u.coorfit Shde.!$Hrvr'e.l rtclirm,vie.).ifintiwat •
7d.Amount of disinfectant used:
3.Well use(check;well use):
Water Supply Well: - 7.e.Scaling fl atciialsused(chcek•all that apply'):
❑Agticultltrrt DMimicipaItPublic Cl Neat Cenicut Grout 12 i3entonitcCliipsofPellet.
Oecodtennat(Heating/Cooling Supply) ❑Residential Water Supply(Single) ❑Sarin Cemeru-Grunt . 1 ❑ Dry Clay •
❑Industrial/Comnncrcial ❑Residential Water Supply(shared) ❑Concrece1610111 ❑Drill Collings
❑irrigation ❑'SpecialtyGruut ❑ Gravel
Non-Water Supply Well: 0 Betstouite Slurry Cl Other(explain under 7g)
INMonitoriite ❑lteetwet
injection Wcp: • 7G For each material selected above,'provide amount:otntaterials used:
❑Aquifer Reel-large ❑Groundu:tter kented'uttian
°Aquifer Stonigc aid Recovery ❑Salinity Barrier.
Bentonite.:81b ,Wtr:lgal. '
❑Aquifer Test ❑Slann}�ater Drainage - ------_- --_--- ___-__-_
❑Expptitrienitll Technology DSubsidetue Control 7g.Prniide a brief description of the abandonment-procedure:
DGc tliennal(Closed Loop) °Tracer
I
®Geothermal(Heating/'CooiinRReturn) . 0Other(explain under-7g) .
4.Dater'eliCs).abandnucd: 10-18723 _ y`
52.Well location: `J O V•1 '' ZU j3 .
Abandoned Station Highway 87 Ir" ""' ^Ft iD:-.-2c cv4!Fi9 UUi,••
Facilitj'101enerNtoro Facility IPa(ifitpplicablc) B-Cet'NQctktioii i;;" O,
8072 Hwy .87 .West Dublin, 28337 . . y '+ :ti 10/26/2023
Physical Address.City.and Zip $'._ Inro Cerlincd Well Coatn:iat or Well.tlwner .pale
Bladen . 0026862. fly signing this farm, 1 hereby cert/y that the u'ellts) was(were)abandoned in •
nty Coa ' lance]IdeniifrcatlanNo.IPIN) tatcorrdatue with!M_OICO2C,O100,or2C.0200It'd!ConstructionStandards-
and that a coPy ofIhir record has boa;fruited-to the well owner.
5b,Latitude and longitude In degrcesdmindfcs/seconds ordeeionlil degrees:
(if welt fa.t<I,urn 4d/inag'issatiiekra) 9.Site diagram or additional well details:
You may.use the back of this page toprotiide additionall well site details or Well
.34.666445 N. 78.729822 W -abaadountetu details. You'nay also aitacii adiiitional pages if iiecessaty.
C()NS`rR11CrICiN DETAILS OF WELL(S)BEIRG-ABANDONED S(iRhtiTPAr.1NSTRUCTiONS. I
:uteri;!lid!coraIntelion rev-rd(s)tl pwrllebte. .I`ar multiple Ilya-tithe or rrja•ta:o'supp/i'
Ireik ONLY with the same ew ti etimeobaIoloim eg I JN£11n siFmit wee Lunn. IOiu. For All Wells: •Submit this fann within 30 days of completion of well
62 Well m :MW22 abandonment to.the following:
Division of Water Resource ,Information Pniecssing Unit,
..1617 Mail Service Center,Raleigh.NC 27699-I617
611.Total well depth: 15 (It.- - .
•I(ib.For inleetion Wells: In addition,to sending the Loran to the address in tUa
• above,also subunit one copy of this form within 30 days of completion of well
6e.Borehole dlarileter 2
(•iu,) abaodomient to the follnwing;
6d.Water level below ground srrfacc 7 .(ft.) riivisiott of Water Resources,Underground injection-Control PrOgrnm, -
1636 Mail Serice Centel',Raleigh,NC 27699-1636 .
6e.-Outer easing length(if!mown): (ft.) .10e,For Water Swint, St inicctton Wells: In addition 10 sending the faint to
the address(es) above. also submit one copy of this form Within 30 days of
completion of well abandorunent to thelcounty health department of the county
Where abandoned, ,
6f.lnnercasing/tubinl;length(if,mown): . :(ft.)
6g.Screen length(If known): (it.) •
Form G4V-3t1 - Nonli Carolim De nrumn1 of Ptwlioatncnt and Natural-Resources-Division of Water-Rcsotuck s Revved Mpg 2013
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WELL-ABAND-ONNIENT RECORD / For lntcnuli)scONLY:
This fpmt ean be used for single or multiple wells \o
n _ I (/ 1
1•Well Contractor Information: `�'`-' WELL ABANDONMENT DETAIL.$
Stefan Smith 7a.Number of wells being abandoned: 1
. Velt'Cettrictortr°ame(Or Willi oxnsr riatia1l)'al>as4tdnguoilonldsdierprapcny) ror andante, hlfemo), or non-wAre strpy'y well ONLY wdth the .sane
eonarocneva jfvrdo)inwni;;Ia neon sabndt rrtefrrrtn,
3576A
NC Well ConlntgarCeti fialliou Number7b.Appru imate volume of Wahl-I ntaining in nell(s)i- (gaL)
. t I •
SAEDACCO FOR.WATER SUPPLY WELLS ONLY:
CQrmatq lranrc 7e.Typeofdisinfiitant used:•None ,. •
2:We tt Construction Permit tl:, Unknown, ,
LEM!flp{Jllcaable welly rntits ri.e.Coo Slate.lraria,i e.Lrjertiur�&lei!Mama 7d,,Amount of disinfectant used:
3.Well use(duds well u ee}: 1 - . •
Water Supply We1l: 7.e.Scaling mutcrials•tised(check all that apply): •
❑Agrictalkutal ❑tolanicilxtUPithtic Cl Neat Centcrit Grout 5l Rcntonite Chips or Pellets •
❑Creothenitat(Heating/Cooling Supply) DRcsicdehti,•tt WaterSupph•tinngle). ❑Sartd.Centeru Grout 0 Dry Cby
❑lndnstriallComntcrdal ❑Residential Water Steeply(Shared) • ❑Count te'Grout ❑Drill Cutting
❑irri iatiou •13 Specialty`Grout ❑•Gravel •
Non-Water Supply Well: Cl Benitonite Slurry Cl Other(explain under 7g)•
»ffMotttioring • 0Recoten. • .
•
injection Well: 7f•For each material selected above,pr side amountof.mater'ials used:
❑Aquifer.Rccltaige ❑Gtnundnater Rentediation ,
❑Aquifer Storage aid Reuivery ❑S:diitity Daniel-
❑AgniferTest: ❑Slonmt�aterDrainage Benton te.:81b ,Wtr_lgal. _, _ • _ _ ___
❑E�perinte plot Tetilriutlogv. ❑Sulasidet�e Cointtil 7g.Piui•ide a brief description of the ubandonmcnt•pruccdure: •
l9Geodtermat(Closed Loop) °Tracer . . i .
•
❑Geothettual(Heating/Cooling Return) 0Othcr(es-plain under.7g) _
4.Dated[{s}.ahandrincd: 10-18-23 :`"` :`n tom• .9 •
•
NOV 1 2023
5a.Weil beattim: i .
•
Pr:-Abandoned Station Highway 87 • It ; :r.•`t" t .. -.s�t
l x
i..:P3 ty
Facility/OmarNauss TxilityiDli(it-aptiliwble) - 8•Cetnlfie tioit +'r;, J .
,
8072 Hwy 87 West Dublin 28337 s ,. • 10/26/2023
Physical Address.City,and Zip' fi' •hue CCrtiticd Well(imatr•lor or Well Omer r .Date
• Bladen 0026862 fly Rigning tits form, I hereby cerffy,,rlmt the well(s) was(were)abandoned it: .
Calmly Parcel Id:firtaitlniNo.(PIN) o MJcrwttianre with!SA IC 02C,0100 or 2C.02(10 W ll Construction Slarriktrds
and that a copy ofthis record has be en provided to the wet owner.
Sii.Latitude and longitude in degrccslnunuteslsccntid s or decim;il dc),rres:.. 1
awaitCrekt,one Iuutnn is'splfia ct1) '9.Site diagram or additional well details;
• You may use tile back of-this page ta_urdcide additional wall site details•or Well
.34.666460 . ...N. .78.729656 . W abaudonntemdetails. Yon mayalso attach aritlitiouapagesifitecessaty_
CONSTR!IC I(iN DETAILS OF tVELLISi BEING:ABAND(/NED `i1BMYTFAi.INSTRUCTIONS.
:heath Udell cutastruetiuu recorcllsl.iJ'ue%uilotle. ,Par multiple urrfettiuit or trin•ustter supply ,
wells ONLY n•iih ibe slime cv)tstrornq 4thaneloteneoL tom cpn submit wry faun. loll. For All Wells: Submit this faint•within 30 days of completion of well •
Gsi Well[Di1:MW-23 abandonment to•the-fallowing: '
Division of Water Re rcis,Infor
mation rmation Pracn sing Unit,
6b:Total well depth: 1-5 (ft.
1617 lll:ril Scnice Center;Raleigh NC 27699-1617
• 10h.For ftilectinn Wells:.In addition to sending the form:to the address in IOa
•
Ge:Boccltolo dlncitctcr:2 } above•also submit one copy of this fount within 30 days of ctnnptetion of still
(io' abandonment to the following; '
(id.Water Fc�cl.bclba ground surf tee! 7 (ft;) Division of Water Resources,Underground injection-Control Pnigratn,
1636 Mail Service Center,Raleigh,NC 27699-1636
Gc,Outer casing lcn h(if Imitn n): (ft) lac,For Water Slimily& Infection Welts: in addition to sending the fount to
the address(esj above. also submit one copy of this fbtnl Within 34 days of
completion•of Well abandonment to the
county health department of the county
GL Inner easing/tubing length(if known): (D•} Where abandoned,
6(4:Screen length(If known): (ft.) ,
Fount GW-31.1 Nanti Corollapu Dctmcnl of Enylroanicnt and N:nurai Resoevecs—Division of Water ltesoietas• Raised August 21113
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