Rockingham_Well Abandonment_20231229

•
WELL ADAND.ONI�IEN.T RECORD A. Fat tet nalUs4 ONLY; I '
•
Tins form can be used.for-single or ntallipte wells •
i,Wett'Contractor information: S WELL ABANDONMENT DETAIL.%
.
Brian.Ewing \ -IL Number of Avclls bciug abandoned: 1
lWeliCanitielorNatne ore.Uol� nally 1bsstitonin;nellonidslirer i n For miirnple .hfecdion. aP swii iYit4 lstirrply -wells ONLY will) .IFe..sm:te
( P 5• NapeY)
cmurnrcftal abrvnirurxa�elt,]ran ctarsitNiut'vuafonic
•
4240-B: - . I' '.
'74.Approimatc volume ufrrat -remai iingusveil(s)r - . (gilt.'
NC•WellContrsgor•,CeitifrcationNumber . • I
SAEDACCO . FOR WATF,R SUPPLY WELLS ONLY: •
• Canepanyl4amc '7 � -
e,Type of disinfixtant uied: .
2.Wdt Construction Peruttt(#:, . '
•L[st all ultfillr uh e-we171iermitv:(i.e...C.uvnly,Sta e,Yiirlarre.ItlrrSur.clr:l Patsy 7dc Amount of dislnfectantu51_iL i ,. .
3: Well use(chccic,wcll use): .
Water.Supply Well: 7o. s;use Scaling inaterlald(checie all Chit apply) .
- -OAgttcultunI : 'w,tunicipal/Ptibiic• . , CINeat Cement Gtuut ^ .. llgraontte Chits orPclicts
, t
• ACrc+ilhcrmal(HC ItinnlCaoling Supply}' ' q[2esiderrtiat Water SS,i}p1y(single) Sand Cxnteul my/" " v 1: U Vg,C '
•
❑litdiistrial/Comnrerci tl EIResidcWi,•tl Water Supply(dialed). _El Concrete Grout •' ❑Drill palings
t7[rritiition ❑Specialty Grout DEC 2.9 20233 Gcnc1 . .
NoaWater Supply Well: -__ . . . .CI Bentouite Slurry " Cl'Qua y(esplailrutarlet7g) '
ll9Motiltorine . DReotety. :draft E:it Pea^ s+ uU
Rx
' Injection WO: - . - . . 7f.,For Oath:materialsele 4111: �r}'ttarideatnautit,of.ntliteHatsreser':
- .IIAquifer Recbjr,e . OGrounthtater Retnediation .
. i.
IlAquifer Storage aixi'recovery LlSalinity Battier 0 Bentonite.:501b ,Wtr:gal. �'
• . Agtlifer Test : OStanmtater Dntitiage
. is
DExperintenlol Technoloe_v .OSubsideiceCannel 7g.Provide liridfdeccriptian of thel.ali;teidome nat procedure: •
gGeoEhzrmal(closed Loop) BTturei • Pulled.temporary well and backfilled boring w/ hydrated •
.DGeothennat(Heiitinlu`Coaling Return} • ElOtlter( plaittunder 7A) - - - • - - ' - -- -- - -- - - -bentoaite chips
I'
4.Datewcll(s).abandencd: 12/12/23 _ _
5a.Well location: • • - j •
Wheeler's Grocery ' • I
ibeilit>thvncrNmnc Fae IBM
_4(ifapplkable)• $,Ccrtificalioit: 1
•
9385-A US Hwy 158 Reidsville,'NC 27320 . • :Brian _Ern }i 12/20/2023
Pll}'sical Address;City,mid Zip .SE2,1411ur of Ceittllial Well Ca, ;tare}r v/ill t)1erL'r Daio
Rockingham • )3y sigirbra 1114 foiiri,I hereby certify that the well(s)ures(?core)abandoned in .
Couui}• : 'Parcel ldanlifaloa No;(PIN) - 'neat-du r n ith IA 1C•AC 02C.01OO.or 2C:0200(fell C4Nslrudflon Starukrnls •
mid thai a copy of this record has bear niovided to:he owl'Owner,
56;.Latitude-and longitude degyres ut tittinesIIccnods'ordecim;4l:degtees: I;
(iNi..ell fold,olio lattloing is snide't) 9.Site diagram or additlonat well details:
You may use the back of this,page to proside.addilional n ll site.details or ire11 •
• • • N. • - •. ' ' W .abandonment detail's..You'may also attach additional pages if itecessaty..' -
I.
CONSTRUCTION DETAIll..S OP 1VELLISt BEING ABANDONED- -UBM TTAL iNSTRUCTiONS I .
:::lath nail'rorivirnetio a marl-italic avollat.4. Poi Mild h iVirt ar'or tain•niuu'wppii
nails ONLY Oh tine sieaae cwisorn;fmiriahnirii,w itnae_toin can rbm l atefini--:.• ' 10a:Ear All:Wells: Submit-ibis faith'_niittin 30 days.of lcomPletion of well
,fia.Well MO:TMW-4 .
'abandonment to die folli wing: •
Division of Water Resonrcrs,Infotmatiots Pruccssing Unit, .
1617.111ai1 Service Center;Ralen ti,1'C 2149971617
6b.Totat.trclldcplti: l7, .) .
10b.Z1ir Tnlectittn Wells: In addition to sending tits font t1Y the addmirss hi EOe
6c.Borehole diameter:1 (in.). abandonment
also.subunit one copyfowl w•of this ithiii 30 days•of-completion of well -e
abandonment le the follawiiig:
•
Division of Water 13esourees;Ui derground[injection GonirillProgramm,
.fiat.Water level.betow ground snrliicc:. (ft.) - 1636 Nail Senicc Center,haler;h,AC 276699-1636:
`, i
6c,Qutt r casing lcn h(if known): 4D.) 10c.For Wiwi-Slimily;f iliteetinu,'yells: In addition to.sending the fora to
the address(es),above, also submit one copy'of tins forth within 31)•days of • .
• completion of well abandonment.to the-Contay health depmlrneut of the county
6f.Innercasing/tnbinglength(i t faftaw•n):7 OWwhere abaitdonctl•
i
6g.Screen length(if laiuw tt):10 . • (ft.) .
.toms GW=30 Nosli Carolina Depopraem afPnvim®mcnt aril Natural Resources-l]vision of PlaicrResalw r ' Reviscd.Augusi 2Di3
F
I •