The URL can be used to link to this page

Home My WebLink AboutRowan_Well Abandonment_20231113 . . • ;„ • \ .61') • • WELL ABANDONMENT RECORD \it For Itilemil UW ONLY'. This feint can tie ar‘ad for singlebr multiple wellS 'N'\ . , I,Well Contractor Information: WELL ABANDONMENT DETAILS I 1 . • Scott Hunt, Jr • la.Number of wells beitigahandtin .1ith - . Wor6„*„,,h,.k14,1,,,:oniato,i,cf:r,'„,,,i,,Ay abbamilia,„im.an jiitte.,.privOly) FOP 1711dIVIV 11*ildit .61' noniraier .sitpply. 'bier's. ONLY alb the -sable •comfrocOOrbirboodisommi,)WU eitoi satmoi MidfilITI, . 4561-A . . - I • 7h.Apprtisimate minim.of Water remaining in welks)9.,• .-..e.'------. (gal.) NC Well cant - • i , ' ''',- ,-1'0::::;:, ,t.,./::(_ .'''') , . FOB WATERSUPPLYW414.S ONLY: . . •---,., ,,,1, SAEDACCO NOV , CampanyName 7e.Type of disinfectant used: I. . ':! 2023 . • , -t in P.L.-7,;:•-(:.-•,),:ts7 ;D.. ' 2.Well Construction.P.erm 1 ,it ft:I /14;•ifi opphev.file:trell permits,11:e_Ctuotv,Aire,Variance,.14,,es'efort„001 tf atom • "-:% ::),:',.; • . - . 7*Mitiutit aldisinfeetsitit tiseilf, • . :: - • •3. . I- - Wel.l.usefehorktritil.use): - • , . -• - . Water Sopply Well:: - , . . 7e.SCalling'nutoni0s:used(clic0 Oil tint;i1)61)");, . • ' pAgisultuial, ciMonieipal/Public al Neat teMent.Grout• - i •0 Bentonite Chip or Pacts. ' .• 1: • Docothermal tlicatinglCoolitig Supply)' I:Residential Water Supply.(singlel ci*.Sd ceiltOl amlit t 0 Dty•Clay ., .. bin4torialiCommor00 • . Clitc'sidotiar Water sppoyoharod) .0-ctinciet .:Gtput . • "'El po pining •.. , _0['ligation-. , .• I:1 Spef431.1.y.druid • 'b Gravel-. • ' . , Non-Water Supply Well . . 0 Bentonite Shirr . Cl Other1(explain-nnder 7g) ... • • .. . 81Monitorine.• - - .CIRecovety ', - .. .. • . , Injection Well - ,- .: . • '• . - - '• ... - . . ,7.C.For each material selected-aboVe,priwide.airtolitit of materials used: • clAnnifeillecharge, • - • OprOundwater-Rent-Ciliatimi- Neat Cem.:471b ,Wtr:3gal.' Sand Cern lb ,Wtr:gal. •lfl'Aquifer Stonige and Fiec;ove0 . :1Salinity Bartier -. . 1 ' • - DAhnirei Test • 0516innwitet Diainige .. . .. -• • .. . Elt‘Tieriniential Ter.:linology 13SubSidence Ccainnl . .., 7g.ProVide a brief description of the abandonment prep.alure: • OGeothennal'(Ctosed Loop) • . ' OTracer temp well;' removal of all pvc pipe and pumped grout from • . 09cothemtal ilialtinoiCooin5 Return) - 00thertexj)lain under 7)p • bottom to top • : : : • ... . . . . . - 4.Dare nellfs).alnindioned: 10-13-23 . - . . . . . . . . , , . 5a,Well location: . • • • • • • . Residential Property . • Facilityithwer Name- Ex-July me(lrimplicablO) 8.Certification :4- - ' - . 640 Rock.Lane China Grove, NC.28023 . 10/29/2023 . . . - . . PhysicarAddress:•Chy.,•and Zip •1;collin;.•0 r,..vato.-.4 Wull cony:max or Well°raw • Dale . . Rowan . . . • •. . Hjr.cigpitig this.fiwni,.I fiereby. ertifp that the.well(st wag(were)iiharidoned.in • Cat!iify- . • PiiCel!cicioilIailkni No.(PIN accoohnice with I.i4 NCAC 02 ;0.1110,or 2C.0200 Frei!eastiatclion Starehirds and that a copy of this record has imen'provided tolhe Well owner,• 56,1.,atiMde and longitude hi degreesitninutestscconds or decinittl degrees; 1. :, . • .(irti•on Om ono.lari1011g is millIeleol) • 9.Site diagram or additional smell derails: . : - • . • . You ma use the back of di pOielb-firovide additional well site details or Well - - . • N - -. W isautiountent details. You may also attach additional:pages if neeisiaty....., •' , . • . 1. C.ONSTIfir(1r1ON.DETAIL5 OF VVELLtSt,BEING'ABANDONED SUBMTiTAL INSTRUCTIONS • - Atrac."/vep-evaaruciean reeordesr if(Ma/We...Por multiple-iNectiOu or not.r..iratp..supply • . . • • • • . • - .iregg ONO'math the soint'cos:atreeti owaeitubuttieut.jOf)eau$.103011.411:efert. 10M.-Far All Welts: Submit iliii form within 30 days of Completion of well . 6a.Well ID Tmw-8 ahandooMent IQ the folloWing: g: ' . , Division of Warp:Resources,InformatinitProcessing Unit,. , . . 1617 Mail Sei-vice(tenter,Balcigh,NC 27699-1617 6b-.Total well depth: 15- • •.1 . (ft) TOb.Toy Inieetinn Wells:- In addition to Sending the formal°the odilieSS-in Hhi above.-also submit one tOpy of this loan.w1th1ii30 days of coinptetioi of well. . • Ge.Borehole diameter:1. - • (in.) abundotinmut to the.following: I ' 1 : . Division Of Water}linen re4,Lintleiground Injection ContiolPrOgratn, 64.Water level below ground tairfacei 12 . (ft.) ' 1636'Mail Serilee Center,Raleigh,NC 27699-1636 - We.Fn r Minter Sootily...C;Infection Wellt: In addition to sending the form to - 6c.Outer casing length Of known): , . _ -. (ft) the address(es) ?bow also submit lone copy of thiS:fbnn within 30 day's of completion of well abandonment o the county health department of the county where aimidoncd.. 1 • '6f.Innet-eashig/tnhing length(if[mow Olt ..(1) , 1 - . . 6g,Screen length(if known): (ft.) I 1 Form GW-30 Nan!)Carallm Dep3rInval cif ErWilfallilleSt aril•Natural Resources-Division of Wrimr licsOluccs Revised Amos/20 1.3 - "' ' - •-•-• ..• • • - • ! WELL ABANDONMENT RECORD For tiitenurlUsoONLY: This foim cats be used forsingte or multiple wells ' • • J.Well Contractor information: WELL ABANDONMENT DETAILS Scott Hunt, Jr 7a.Number ot.wclls beilt abandoned: 1- ' Well&urretorNaute(Or%milownu j arsontlly obbnitoning ncll.ou b shier prupny) Far rendrkble ti ferlme or :—iptr(.r .supply' welts. ONLY isiib the 'sawe corastructioniahatrdolrmenat,ibncanstilwutoneforr, • 4561-A WC 1VcI1 Conlmaor CenificaLion Number 71p.Approximate volume of water t retu well(s)9 in cll(s)Q (gal.) sAEDAcco FOR WATER SUPPLY WELTS ONLY: Coropan}Name' 7e.Type of disinfectant used: 'n•- 7: I., ti _ y .,� 2.WellCotistruction Permit I:, . NOV 1 !; 20 Lat pHupplkYhk uelperrnitr(1.tt Coat,'.Si*,Varlru c e.Injeci on„eltJ if lG in, 7d.Amoitn t of dhlnfeCtslril u ied: L 3.Well risk(ehecic well.use): ie:',,", ,_ 1.:.::1 . 7e.Sealing inutedalsused(chccl,ill that a is . "�'~ �ltatar supply well: s pn.�)� • ❑Agriculturat • ❑h$tnicipal/Ptiblie. W NeatCcment.Grnitt• l BcmoliitcChipsorl'cllets ❑Geotltcrrnat(Hcating/Cooling Supply) ❑Residential Water Supply(single) El Satin Cement Quilt El DzyClay . plru[nstrial/Commercial OResidenti4r Water Supply(sltaued) p ConcteteGrout ❑Drill Cutting s • GlIrrigation Speciglt}Growl' . 0 Gravel Non\Vatecr Supply Well:• 0 Bentonite Shiny ' El Other(explain wader 7g) .I9Monitorine. oRecovety ' Injection Well: . . . . 7f.,For each material selected alior•e,Onside ausottot'af attiterials used: • ❑AquifcrRccliarge ❑G.riiuitdttaler-Rentednition Neat Cem.•471b ,Wtr•3ga1. Sand Cern.•lb ,Wtr•gal. • -Li At uifer Storage aixi Ricovety OSalinity Harder . .❑Aquifer Test ❑Siorntll'ater D aitalge - .. . • • DExperinleotal Technoloeye OSubside»ce Cottitni 7g.Proiide u brief description ofthe ub:tiidonment procedure: • • ❑Geothermal(Closed Loop) ❑Tracer temp well; removal of all pvc pipe.and pumped grout from . • ❑Geothertual(Ii iann1Cooling Return) ❑Other(explain under 7a) bottom to .top .3.Date tt'sit(s).abltndoncd: 10-13-23 'i 5a.Well location: ' Residential Property ' Facility/Bun r Niuw Facility1Dk(fapplrablk) 8.Cei1iRcatknt: 640 Rock.Lane China Grove, NC 28023 10/29/2023 P1iysicaFAddrcs,City;arid Zip IAWL:,-(;ti.int leuig...a,1 -'eil Corurrctnr'er WCII°ra r- Dale 1. Rowan . . - By cIgning this,farm, I iiereby.ceihtify.tliar the ire/1(s)war(here)abandoned in 'Comity • Parcel Idcnlillgrina No.(PiN) pccvtrhtlace with'I5.2 Art1C-02C;:0100.ur 2C.0200 n;Il CarisInlction Standards and that a copy of I&is record leas been provWeetto the well oisner. • Sb.I.ititudeand longttut!eIn dcgrceslniinntcsfscconds'ordecimal degrees: (if troll fi;td,one.Iii1111ing is.snllkied) • 9..Site diagram or additlo not well details: 'You may use the back:of this page to provide additional well site details or nell N. . -W abandonment-details. You may also attach additional pages if necessary.' CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED 41.11131FtiITTAi.INSTRUCTIONS . :ttla h held cvartrueirurr.curvy-. sj'y'ovaila1k, 1 or=Jr/0plr alJeco ur or tarminier supply ire&Ls ONLY ii-Jtb AT saute.rwcrarxuone'rziarutourz,en.irou caunrlatol.cure frntc • 10a:-Far All Wens: Submit ibis•fain within 30 days of.complction of well • 6 i Well ID :TMH?-5 abandonrneut to the followinG: ; , • Division of WaterResuurcet,InformationProcessing Unit, Gb.Total well depth: 20.5 • (D:) 1617 Mail Ser iie,Center.Raleigh,NC 27699-1617 10b.For in legion Wells: In addition to Skending the form to the address in Ida Gc.Borehole diameter:l (ht.) above.also submit cute copy of this form within 30 days of completion of.ell' - abiititlotintent to the following: Division of Water Result ri:o,Underground Injection Control Program, 6d.Water.tevel below ground sitrface:1,2 (ft.) •1636'Mail Scrideetenter,Raleigh,NC 27699-1636 10e.For Water Spplily 40u4'40in% .tts:. In addition to sending the form to - Gc Outer casing length(if known): (fw) the address(es)above, also submit one copy of this fouls within-30 days of completion of well abandonment to the county health depannteid of the county (If.Innercasing/tubing length(if!crown): (ft.) where abandollcd, 6g.Screen length(If known): (ft.). I • Form GW-50 North CamWn Department of Fnvlinumenl uai Nalurat Resoumcs-D151510n of WarcrRoouires Revised August 2013 WELL ABANDONMENT RECORD For triteritalUsi:ONLY: ! This forth:can be used far single artuultiple wells 1.Well Contractor.Information: WELL ABANDONMENT DETAiLS 1 i Scott Hunt, Jr ' 7a.Nimrber of wells being ubandutied: 1 WcliCouoaetor Nome,(or nett owner persondllyoh:l laninguell.onlu herpraperty) For rotrThpfe ,Jeetiar Or mn iarcr supp( dells.. ONLY •wltb the -sone earn ttennalabalkianinent;you van.rn Inlrareform, 4561-A . 7b,Appni cintate tolume of Water•tiLittaining in well(a)Q --. .. (gal) NC WellConlinaor C i115cnlion Narntbcr , r c'-'�", FOR WATFRSUPPLYWELLS ONLY: '``-_. r, ' l SAEDACCO NOV j r Company Nano lc.Type ordiainfectant Used: 21173 2;Well Construction Permit#: :r.'� ' Ltst all allpiteatile well perm1LY(i.ct teem',State.Yariaacia•In ecifioa,.ere)tfll'nursn ~D.•,. •: "ry 1- ;"' 7d:Amount of disinfectant used: ...), a 3.Well ow(citedct•ell.use): Water Supply Well '7e.•Sealing matenals-uSed(cheek:all that apply): ()Agricultural OMunicipal/Public 111 Neat Ccincnt.Grant - ' . U Bentonite Cbips or Pellets. (1Geothermal(HcatinglCoolingSupply) ❑Rcsidential Water Supply(single) ❑-Sattcl Centeitl Gmut •❑Dry Clay ❑hulnsirinlI ommctcial ❑Residentud Water Supply(shared) .0 Concrete Grout • ❑Drill C tuin is • ❑irtieatiou •. - . U Specialty Grout O Gravel. .. . Non Water SupplyWeil: . .0 Bentonite Shirty ' 0-Other(explain under 7g) i9Motdlodng•. oRecoven' . Injection Well: 7f For each material selected'abote,provide amountof materials used: ❑Agttiferltecltaige. ❑G.munth;tier Rentediution Neat Cem.•471b ,Wtr•3ga1. Sand Cem..•lb ,Wtr:gal. OAgitifer Storage'and Re.OVery ' US.dinity Barrier ❑Aquifer Test OSlonnivater Dntinage - pExperintenlal Techuoloer DSuhsidetce Coulml 7g,PitWidc a brief dccriptian of the abandonment.pittetyylure UGeothernrtl(Closed•Laop) ®Tracer - . temp well; removal.of all.pvc pipe and pumped grout from OGeothemtal(Heaung/Coohng Return) . ®Other(esplain under 7g) I. bottom to ,top - j ' -, . • 1.Daten'cll(s)abrttidoncd: 10-13-23 5a.Well location: Residential Property 'Facilityl(hvncr Nruno Facility 1D0(ifapplierble) 8.Cet of lc idrron: 640 Rock Lane China Grove, NC 28023 tit 10/29/2023 Physical-AddroSs:City,-altdZip . y(0;inceerr:.suzX•cil Well Co/antoorUr Well Owr r Dale Rowan /T y'.tigattt�c•thisform,-I hereby certify that the wants)was(were)abandoned in County P.uccl ldorrilltC ii)riiLNo.(PiN)• accardaour with It I CAC 02C'.0.1,00.ar2C.0200(Cell Cs'm i-lir: On Stanektrds wild thiitacopi ofibis'ward basbeenprovided(allieu'dllowner. 5b.Latitude and longitude in dcgrces(minutcs/scconds'or dceinl;il degrees: (trwelt r4kl,one b ootg'tssir173cicuq -9..Site diagram or additional,well details: 'You may use the back of this page to provide additional moll site'details.tir toll. N W .abaudoiunent details. You may also attack additional pages if tlecessan'. •CONSTRIIC ION DETAILS OF WELL(S)BEING,ABANDONED 4UBMTiTAI,INSTRUCTTQNS :Atkin,itell rov aruerlan r,cvrdfsf if uvaileOfe.-tour multiple hidciion rr lien-uxrh iigspiy treils ONI Y with:h ea wire arurstreettadatmtihumtcau.i ea Calm m bmit ere fume ' 10a:.Fur All-Wells: Submit ibis Tam within 30 days of-completion of well 6a.Well ID€1:TM W-1 abandounicnt to the following: Division of WatcrResuurcrs,Info rnwtion-Proctssing Unit, . •l 29.5 I617IItailu-S ice Center,Raleigh,NC 27699-1617 . db.Total Well depth: .(ft.) • -10b.For Injection Wells: In addition-to sending the form to the address'iu 1 a Gc.Borehole diameter.1 (in,) above,also snbndt one Copy of Ihis form within 3Gdays of-completion of Well abandontnent,to the following: •Dlvislou of WinerResourcd,Underground Ittjectlou ControlPrt6gram, bd.Water level bclon•ground surface:20 (ft.) 1636 Dish Scinicc; cntcr,Raleigh,NC 27699-1636 yyp!C Gc.0u1cr easing length(if!mown): (ft) tOe.For Water Sunnis.Nt iuieetinn Went: In addition Ur sending the form to the address(es) above, also submit one copy of this fbtni within 30 days of completion of well abandonmcn i ccA the county health dcpannicnt of the comity 6f.Innercasin„/tubing length(if known): (f,) where abandoned, 6g.Screen length(If known): (ft.) Font GW-30 Minh Carolina Depart:um:of Enviromncol mall Natural Resources-Division or WSterResotuc s Revised Augus0 2013 I ' 1 . •• .. WELL ABANDONNIENT RECORD Fat lintimal.UsiONI.r.• It. This rota can lie used ii*single:or untitled welLS • ' , . 1.Well Contractor Information: WELL ABANDONMENT DETAILS Scott Hunt, Jr . la.Number of wells being abandoned: 1. vklrec,iirllefi-irmnic(i.,,,,,a16,-in,,rietsq,,:iiii;abbiihnh,ii,;jii.iin Lisiki p4i,•ci5y) • For :multiple- Injertfatr -Or- nbri-tilafer jupply. kielfc. ONLY with ibe MAC noratructIoiPabautialime.nr„wri co.,,submit Ofidfill711. 4561-A. V. . I L. • 7ii.Approximate voinnte ofWater.remaining in Well(aft - (OP rie iNcll ConliadOr CO 41011011 Tilliliiari • • '' " :- " • • • , - . SAEDACCO . FOR WATIM SUPPLY WELLS ONLY: '''.6—•'',--' — ... ',• .e i,„„i,..,„) Company Name . 7e„Type of disinfectant Used: H .. . ., NOV 1- f' - : ' • 2.-Well Construction Permit Ai,- , • - - • . Lut 41 opplfroble well pvitorily.0.1.i.Cvarliy.$t4-#.11.0witv.Injecliotr,: k.t?Anoint . 1,.-73,... id Amniotic of dLsinfeetatit Used: 3.Wiii u5i(heel:Well use): . - . -....:,-;,..:-::::,..;:'1.,-,::;':-:•:. . - . • Water Supph Well • . - . . •7..e.S'enling_Materialq-Used(cheek all Mitt apply): pAgricultuml ' • ClivIturidipalfriMlic 11/1 Neat-Cement Grout' .. 0 BcMenite ChipS orPelle1S:. 0GeolliCrmal(HeiningiCooling Sapp()). 01icsiclentbil Waier Supply(single) . a 4ltd•Cemegl Grout . •0 Dty'Cluy 0 hubistrial/CommerciOl: Oltesidential Witter Supply:(shared) •p-C.ancrete'.6N•1!I' ' . . ••0 Oa'C4t.tinp, 0 litigation' , • . ..• • - -• b 1:tt,intly Grout .. • 0 Gavel . • •. ,. . Nog-Water SuliplyWetli . . CI Bentonite Shirty. . : 0 Other(e.xpliin under 7g.) . Monitoring V ' . 121Recovety . . . . Injection Went • . :. . . . ., •7.t.Piir each material selected aliovei.ppaside anion-Or oftmiterials ttNed: ... ,. OA'quifer*eborge I:quit:11*We*Reniddligion Neat Cem.:471b.,Wtr:3gal. Sand Cem.:lb ,Wtr:gal. IZIottier Steptge Mal Recovery 0Saliaite Barrier ' ,.. . _ . , . 13Aiptifertest OSMinniater Drainage ..,.., . . . . . . . . Inftsmenutental TeChuoiogy •0Subs,idence.0aranl 7g.-Pro•iclei-a briefdaeriptini of the aliatitianniem procedure • . OGeothennal(Closed Loop) Effracer temp well; removal of all.pvc pipe,arid V . " pumped grout from DGeothennal(Heating/Cooling Retort]) ClOthentexOlain under 710 • . . bottom to top .I' • - • . . , . . V. • 4.DliteWettw.abandonc(j: 10-13-23 . . . . . 5a.Well location: i • . . • . • • . Residential Property . ! V. Facilityiewnr'1,1*6 Facility IDs(itimplicable) 8.CertiReation: , • 640 Rock.Lane China Grove, NC 28023 I.- ' 10/29/2023 • Physical'Actiltrcs.City.;-thiti Zip . . _. . . WO Contractor:or Well Owiv.r. • Rowan . . - By signing this farm,.1 hereby crtih that the,weEN-wag piwtt)abandoned in- - • Can* - Parcel Identitletilioil No.(PIN) .;accortlatice with 15A'VOW 02C01.00.or 2 d.0200 frialkinisfructign Standard. - • and that a copy ofthis record has'been-Pravidedta the well owner. 5b.Latitude and longitude in tlegrces,intinuteilscsondsnr di*Imal-degreeF [ ,,• orli•earEetd,one latilong is,vorhcien) 9.Site diagram or additional well details: . • • , .. You May use the ha.).of this page to provide additional well sites details,Or Well . . _ _ _ • • • • W - abandonment details. You tuay alio:aim&additionalpages if meths:try. . CONSTIt11(..110N DETAIL'S OF WELL(S)BEING ABANDONED ,5tntivrtrrAt,INSTRUCTIONS . :Moat Idl.ropstructiao rer.vrti(s)if available.. .FOr ira4tiple kitectictie or a..inoiriep's4ipply we*ONLY1i10 ti.!smite mitstrationligicurtforyment,.loti cpu Aulutth pit,faiiii, 10a:tiror All Welts: Submit this form within 30 daya of completion of abiindOomcin to the following; •! ', 6a.Well 110:Tmw-2 . . . • Division of Watertfisourem,Information-Processing Unit, •6b Total well depth 29 5 fft) 1617-Mail Service Center,Raleigh,NC 27699-1617 . : . • ' . i . . .. . . • . lob.For.Inleetion Wells: In addition to sending the form collie address in IOu above.else submit one CORY of ibis'fain within'30 days.of comptition of well 6e.Borehole diameter:1 (in.) ubandonotent bathe following; 1 '. • • Division of Water ResourieS,Underground Injection Conn:M.:Program. • 6d.Water.level below ground surf:tem..20 (it.) . •1636 Mail Scriiice Center,Italeii,NC 27699-1636 i 10e;For Water Sunnis'&!Weed-nit Wells: In addition to sending the form to -. 6e.Outer casing length(if!mown): • (fti) tile address(es} above, also submit one copy of this.oun within 30 days of completion of welt abandanmeni to the county health department of the county , I where abandoned, 61.Inner casing/tubing length(if'mown): • . (ft.) ! I • i 6g.Screen length(if known): (ft.) , t I • 1 . Fenn GW-30 Noah Carolina Dcpartiona Of Enviroomcot and Natural Resources-Division of 11Vateresourees Revised August 2013 , . ' • z :,- , • • . WELL ABANDONMENT RECORD For hilentai Use 01,ILY" This forin caii be uSetilbrsingte•or multiple wells' • • . 1.#0 6110:actor Information: WELL ABANDONMENT DETAILS Scott Hunt,• Jr la.Number wells being ahantiOned: 1 - • . • 'NellCovteaetOrtianieior.WellOci*perisonany_qlnimtoiiln?,Ssellan hrs/her praPeny) For oarlople hijec'iron or throllititer supply lolls. ONLY Orb the •sorrie •eorrstritchonfOrboirdorimeni,ma crorsobriir onejarot. 4561-A • • 1 !! , • -71i.APpriiiiinate yid-nine errata.reintiMing in sivell(s)9 - (RaL) ! - ! NC Well Contracitir C.401000)1:Numbet • SAEDACCO , . FOR WATER'SUPPLY Wf3.1.SONLY: . , .. .... .-..: Conany Name! . - -.--- ,I...,„ • 7c.Type Oldisinfectant USed: !. . • I, • - NOV 1 3 2023 . . 2.Well Construction Permit 0:, , . • i Liu all oppproble well porirri,s g.e.,Coardv,Sarre.Poritinth.Iftjecnon,..44 Omen. • • . ,7d.AitiOutit of disinfeetant used: 3.'wo!usi Oicpkweu.usi4: . . f.:.;';';,-.---..,......,,''''j'•-:i",::i - • • • -- Water kupply Well; , - '7e.Sealing Mated*Used(cheek all that apPlyY: . . . . . • pAgricultural. 1:11%lunicipal/P0.11..e. . IX Neal Cement Grout Cl ft.cMopiterChips or Pellet's OGeoltermai(Heating/CoollngS1MPID• ,-°Residential Water SOPA'(single) " 0.5anticanteM Grout • 0 Dry-Clay . • • 0 IndustinaliConnitemial " OResidential Water Supply:(shared)• •.1=1 1c6110!Yeia9!91!.":-: •" •'0 prig pith* . . 0 Inigation'• !, • - ...• • • . p Specially Grout . 0 Gavel !• •__ ! . Non-Water Supply-Wcilt' . . • .::._ 1;1 Behtonite Slimy . . , - Clm•Oilier(explain. under 7s1 E1Mon1torine. . .. . , . ORecovety „ , "InicOPP!Wel1; " ' . .. . . . . : . . . . :. -.. 7f.FOr each material selected:thrive,provide amotnitof nniterialS used: Claiquifer itsechatge OGrOunduater Rentediation- Neat Cern.:4 71b.,wtr:3ga:1. Sand dem.:lb ,Wtr:gal 10Aquifer Storage mkt Ftechvery 0Salinity Barrier !. 0Aimifer Test - • OSIOninsaler Drainage- • - •.. . . . • • •. . . . • - - • „ • . , 0tverimeinal TeChnolog 0Subsideticetonioal 7g.Provide a brief:ascription of the abandonment pritectliiret OGeothennal kCkseci Loop) 0Tracer . . . temp well;' • removal.of all pvc pipe.and-pumped grout from - 0Geothenual(Holing/Cooling Return) • . 00ther(explain under 7g) . bottom, to top i! . . . . . . . , . . . • • .1.Date Well(s).abiindonetk 10-13-23 • . . i • .- . . . . . . 5a.Well location: • ' • • Residential Property • - • . , . CertifiCallitm Facility/Owner Niunc Facility IDg tifapplicable) S. - • is • . 10/29/2023 640 Rock.Lane China Grove, ire .28023 . . . . Pli.Vsical•Addrets.City.-and Zip • -4Coann:i. orteltkiks.1 Well co enactor or Well Oivarr, Dare Reeiran . • . , - . - . . Dy signing MO farm, I hereby cyiffy that,the wellt.y):leas(n•grO)aPaadoned in ' Comify • P•ael!dentine:n(6a No.(PIN)• accardaiim iitigh15.4-NOIC 02C;101,00.or 2C.0200 rFe'ell Construction Standar4 . . ' • arid!kit a copi,of kis iec,:ar•ii has ilMi'laivvitleil.tpilreivell c"nraer;• . 5b.Latitude mid longitude In degrieStrotituteStseionds'or deciiMit'degrecs: . . , • . • : I': i. , . . (lr,koiroi,ow.latnoits is soimigi ) 9..Site diagram or additional well details: . . • ' .. You'may use the back of this page to Provide additional'mil site details.or Weil , N . W .abandomitattdetails:You may alio attaeli.additional'povSif neeeisary: . , • CONSTRUCTION DETAILS OF WELUS)BEING ABANDONED , •SUBMITTAL INSTRUCTIONS, Math 1141 coratreerion rocorrlisi if ovirOlabk..•For iradliple byeethly to trunolvigp'supply. - • ivelts-ONO"with the santq.corrstruotion/Olkorihronart.you con sirloin'',pre form ' 1041,For Al! Welts: Submit ibis font Within 30 days'of.conipletion of well - • 6a.Well illii:T4 . abandOnritent to the following: - !" " DivDivision of Water Roionrets,•Information•Proc .sing Unit,. . 0b.Total well depth: 20 . (ft.) 1.617 Mail Serviee Cettwr,Raleigh,NC 17699-1617 1 -- 10b.For hileetion Wells: In addition to sending the forth to:the address in i0a above:!also.Submit one copy of this!form within'30 days of-completion•of welt 6c.Borehole dianteter:1 (in.) abandonment to,die folliswitig: (! , • . • Division.of Water RcsOureek,Underground Injection Continl-Pregram, Gil.Water level below!mond surface:.12 (i.t.) ' 1636 Mail Service Center,Raleigh,NC 27699-1636 1 " . 10c.For-Water Sunnis.&Infection Wells: In addition to sending the form to 6e.Outer casing length(if known): __ _ .(fL)• the address(es) above. also subniii.one copy of this fomi within 30 days of completion of well abandonment to the county health depot-mend of the county • where ahandoned, • 61.Inner Casing/tubing length(Iflaiurvn): (ft.) • . • ' • • . .6g..Set*n length(if known): . _(ft.) ' . • . • , • • FOIllY GW-j0 Ntinh Caoallin Depeiniocoi dr awironenzot end Natural Resole-us-Ethisfon of Winos goit'Ances Revised Augari 2013 . .