Brunswick_Well Abandonment_20231113 (4)

WELL ABANDONMENT RECORD For imcrnatUscONLY;.
This pim can be used for single or muhiple wells'
1.'Nclt•Cantr:•rcibr Intormaii0n: %VFLL AliANDONPr11r"_N't DETAIIE Sj
Stefan Smith 7p,Number of ivells being al►anda Icdl:.l
R'cltCotica'clorNanM(orta�l(oursrpuSori�(ly:ds� farilneix�tl6uhisi)rtirprupcny) or fividople Inlertiorr cv a�ta-vYttr� irr,�l�+ galls MILD wide the .snare
. rettarrttrcrriauit'=nndruinter+t;lYlrlcvuP,rlfvru wrefirrn
3576A
7b.Anpro�:iirrate�•A inc of*titer rre i iniag in pit l(s)<1 (g tL)
14C Wc13 CoOwdorCcnlRitBou Nnnhei I"
SAEDACCO F01R NVATERSUPFL,1r WE1,i.S O LV:.
Ccirty lvan!c Te.TN•(te 6f disinfi., fyrtt gscsl:None
2:Weil Copstruction Permit#:
1d3tcNlvlipftaerblerrrl/larmilv(t.a.Ctnrittt',Sluts;)'Jrldrtie,l/lartlart,.etctffkttatrN Td Amount UftliSlnfeltunfnsrvl:
3:Well usr"(chiickwell use):
Witer'supply\Well: ^te.Scaling[n;itcaials scd(cUcciAl.ihw tapply):
pAgrici►itcirtl bIkfunOpali tbii.c IA Nc~i CcRiC64.Gtptrt I Cl Hcroonitc Ct*orPcllcts
QGcotIx=tt(HcatinVCpolina Supply) CjRcsi&ntLjj%itet Soppt)•(sinriq) ❑Sand Centrist GttSut n i)ry Cl n'
171ndusubliCommen:ial Supply(sb,•tned) 17 Concteta'Grout n Drilt COigg$
nlrii •tiou n�Spec�iutt}'.Grout n:Csnrel "
Npn!Pater Su)rp(N•)Vella - 0 Hooke Slmq 0 Outer(explain under 7g),
1>Dlaionuoribe nRc oien
injection Weit• X.For.each"material selccted'aba4'c,p4n�ide anwunCo f.rttatcriats usccl:
nAq"nilerRccltarge nGnituidt<alerRcntcd'wtian .Neat-Ce'm.:941b ,Wtr:7gal.1 Sand Cem.:1b ,Wtr:.gal.
pAiittifer Staargc uiki apLi)t eti 17Sctlinity'Daiticr
Bentonite.:31b ,Wtr:gal.
nAgniferWst I7Sldnnyt'iiterllntiitago. _
nEx:pgrintentalTieclutoloey i:7 ubsideme Corttrul . 7g Frtt%tdt a brief d criptian of tha ahaadnamcnt payiccducr:
Meo&nnal(Closed Loop) OTracer
®GtrothemxiltHttinw'Coolins,Retum} ®0ti�rlesplainut►der7 ) Pulled entire well and pressure grouted bore using Portland
cement and bentonite grout.
d•`D,atcu'ell(s}.abanddncdo 10-17-23 7 r� ` •'"N
Sa.Weli Eucrttit►n: �,
ExxonNobil " N O V i—1a,20g"
i
$.Cer4iftcitiair .�
F.tilit?•l0ivi>L•rNwtn: Fa;ilitrlD�Cfapttliablc) � ifle :r"+1�`';� ��T��¢{;:
1515 River Road SE 28479 tJ V} S� 10/26/2023
FhysicaFAddress•Citp:and tip hrct,e•Ccelil?4ti1 Wal Cnntrtclai orit+Cfl a+'n.K Uale
.Brunswick . 41,signing.11tlsAr"I, 1 llemhy Curt,v that llte u•c11(sj,wgs(trere)a0imdoned in
Caunly, t'arcclld::fairki iNo.(PIN) - '(k6hlanvc irillr"15d e}�itG 0'C;0100 ur 2C.42CtU fifcll CQiislrttctlurr Slaniktrtls
rrrrilllrrif aicnp�ropliereeorrl htrsbee a,pn?v"idcc!(a the-well ou7oer.-
-Sb,Lattitudcaudenngitutfcinrlc�iceslutit�uic+Osrcnndsot•!irsini 9;tlegtmcs:
[Ifnetl fxh1,ut�4itllo+tg.issitliicicrw) 9.Sito diagraru or adtiitianaEu'cll dct itt9:
You;rap;use the bb&of this pag8 ta.{10"vide_Aditiottid well§Ie' .dens or Will.
34.181693' . * 77.988957
. _ h \Vsdiaudoumettf deutils. You twN'also�ttaeit:ttiilitioual'�b�s if tietx�saty_
CONs,rR11G'1 ON DETAILS OF WFI10 l!11ONG ABAiN1)iD111ED -SUBAii MAi INSTRUCTiONS. '
:Ittach 16wll6rulrrrcflein icrtrclra:+-ij'uiiaL241a ,fur+rirnlnpro hVer iaii 6r•'rxin4intiL•=Pptl'
a,e16,0Ay trlift fim iad; For All SVe(ic• Submit Ihi5 fonir nittiin 30 days of completion at «-ell
4 Well iHW1R abauilonuicnt to tha foilawi.0g:
bir,�ision of�Vrtrer L4esouit�,ia��rmitiott"i!rticc+isin�.Unir,
IG17 Alail Sce�icc Ceutcr;Ralei„ ,ItC 2ifi99-16L3
6b.Total well depth: 13 li
(R,), i ,.
i0b.rnr iniccAnn 1Vclis: In addition:fo ndiug tl►o(Drat io ttte address in toa
fie."Rtit�ttolc dlaatctet:2 (in.)' abo�r,atso subuth,one ei►py of this'Conn NFithiit 30 days of comptefion of;well
abiindoniiierq to the following:
6tR�4atcr IcFcl.bclpK 4 mislon of Water Resouved,Undergrrtitad Ynjectiuu Can4rvl Progrntu,
grr►uud wrfacc: 00 i63fi Mail Bermes Ccatce,Ral4gh,KC 273699-i636
6c.Qutcrcosing length'(it bin n). 3 (Ct;) 1(Ic Rae Water, rLt ill tom. bu tinm,}F'ctly: Irt addi6an to'serbdina ittc iomt.to
tl}€:addss(es) abode. aisa.submit bab agpy of this tbtnt within 3Q days of
Completion of well abamlontnent to the county Faith depat•Inicitt of the county
6f.Inner crrsitiWtuhin..length(if,[mown):. (ft•) *hers abandoned,
6g.Screen length(if known):10 00
Fonn C,O'-30 Nolth Carotin Depananm ofEn unniem and Naluml ileso=cs-Dit•Islonof Water Resounds ltcb,ccd At guq 2Ot3
y �
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