Haywood_Well Abandonment_20240116

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WELL ABANDONMENT RECORD V For Imemal Use ONLY:
This form can be used for single or multipte wells
t.Well Contractor Information \ WELL ABANDONMENT DETAILS
Rich Lemire 7a.Nwnhherof wills being alandanal:
Welt Contractor Maine tor toll uw petsonally aln miming%tellont+istIJerpropeny) Far multiple hJecrtoir cu• m.m-miter !supply. wells ONLY with the same
Ca'Lcrriyamildwfn ram mf,nitt can sutwrl(one firm.
• 2593A I +
711.Approumatc ralunteofwa1i remaining in Weli(s): („al,)
• t4 \vdl CbnlractorCertiiic,alion Nunticr l!
SAEDACCO FOR WATER.SUPPLY WELTS ONLY:
Company Name . . 7e.Type of disinfectant used: . - .
2.Well Construction Permit 1#:, ,
List ell uppltevMle uv71 pvrrnitr(ir Cuaiafv,Sane,Yariaecee.hrjectiun.etc.)tfbrawl, 7d.Atttotmt of dlsinfeetlnt'uscd:
3..Well uae(cheekwell use):
• • Water.SupplyWell: 7c.Scalirng materials-used(cheekall that apply): •
°Agricultural DMtinicipal/Puhtic a Neat Cement Grout CI Bentonite Chips or Pellets
aOcothcnnal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand.Cernent Grout .El Dry Clay •
❑lndristriallConrntcreial ❑Residential.Watcr Supply(shared) .a Cottciete Grout 1; O Drill Cuttings
i]lni ation I7 Specialty Grout .❑Gravel
Nan Water Supply Well: ` D Bentonite Slucly 17 Other(explain under 7g)
181Moultorine ❑Recavety . .
. injection Well: - 7f,For each material sekcted above provide autotmt dfaitateiiats ttscd: '
❑Aquifer Recharge . EIGrouiuluater.Rentediation
°Aquifer Storage and Recovery °Salinity Barrier
. Bentonite.:251b ,Wtr:gal. is
- OAguifer Test °Stomnwter Drainage - • -
• DE'perintetuat Technology . °Subsidence Control 7g.Provide a brief d_caeriptian of the,aliandunment procedure:
EIGeothen»al(Closed Leap) - ' ClTracer i.
Pulled temporary well and backfilled borehole w/ hydrated
®Geothermal(Heatingi'Cooling Return) ; ClOther(explaiu under 7 )
bentonite chips. .,
.12-18-23 „ 1 „Mao' '' y 4~�(-'•
4.Datewelt(s)ahandonech �,t y r e
Sa.Well location: ; JAN j a �02n
Burress•Residence
lbeility/OtrrrcrNawe Facility IDN(fupplicablc) .8;C'ertificatlait: IftiY;rri, c {Siojn� Y7:-•..,n.- �UR '
89 -Rattlesnake.Branch itd.--Canton, NC 28716' . - .. '`.... '�t(J /I+st^rL 12/18/23
Ph ysical Address.City.and Zip 'Su turn of& irrcd Well COutiaiar or Well(hstur [Mu
i.
Harwood Hy.signing tlas Aria, I hereby certifyI:that the well(sJ was rir j abandoned in
County Parcel Ideeittaitinu No.6PINj accordance with IS.4.VCAIC 02e.0100.ur 2C.0200 fre11 Cana'lntclion Sttmckirrls -
arid that a cop rifthis record has been provided Nate n eU owner.
5b,Latitudeand longitude In dcgi'eestntinittestscconds ordeeinu'tl'degr•eesi ),
Of dell fa Id,a+rc iatilo;tg it:s ttr>Licty) 9.Site dlagrans or additional well detalls:
You mak use the-back of this page to.,petiiide additional well site details or well
N - • • W abandoimtziu details..You may also:utaeh addiiior>;tl pages if necessary.. '
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CONSTRUCTION DETAILS OF WELL(S)BEiNG ABANDONED SUBAIIi ITAi.INSTRUCTIONS '
.-Itfudr uo/I cvrrrtn/diet)mirrrd(s)'If aVallahle. •Fite nndoper nrjection"a•rsea•watcr wpplp ' -
weils ONLY with the swim'cwistructiort'ahanikn{great.)urrcar uhnifi cute j<rnrr. • Itla.For All-We11s:' Submit-this farru within 30 days of completion of well
Ga.Well IDi3:r4-.03 abandonment to the following; I;
Div'isidn of WaterResnurFes,Information Processing Unit,
Gb.Total well depth: 15 ((p,) 1617 Mail Service Center,Raleigh,NC 27699-1617
1011.For-infection tWells:'In addition to sending the form to the address In Ella
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fie.Borehole diameter:l (Cn y above.also submit one copy of this loon within 30 days of comptelioa of Well
abandonment to'the following:
Division of Water Resources,Underground injectlon.Couthil-Progr:tm,
6d.Water level below ground surface: 0.5 (ft.) 1636 Mall Smut Center,Raleigh;NC 276!)9-1636
6eUutercasin Icn.�{r.(iflat}vvu); (�.) lat.For-Water•Surinlv•dr.iiriretinn1Wells: In addition'to.sendingtheformto
fi gh5
the address(es) a6oe.also submit one copy of this roan within 30'days of
completion-of well abandoiunent to*county coiWy health deput-Irma!of the county
6L Inner meting/tubing length(if!mown): (ft.)
where aixtndoned,
6g.Screen length(if latonn):10 (ft.)
Fotnt GW-So North CaroUtn Depantocut are:Ma nnenl moil Natural Resources-Division of Water Reno uc s Revised August 2013

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WELL ►BAND.ONNIENT-RECORD For Internal Use ONLY;
This'foim can be used fen single or miiltipte wells
I,Well Contractor Information: WELL ABANDONMENT DETAILS]
Rich Lemire 7a.Number of wills being airandnuel 1
Well CotitiiiosName(onulloacerp:isanatlyatbsrtonfug,wllunligtlirpiopcny) For reidnple injection or' non-Hwfal ;supply wells ONLY kWh the .soau
CoatstrucfMp•abaiuLatinunt,lwre can submit fiefarrn
2593A
71t.Approximate volume of mite remaining in ti•ell(s): • (gsL
NC Well CtntinclorCerlitctcatioti Nntiher i• ., •
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
Company Name le.Type of itisinfectant used: I' - -
2.Well Construction Permit M:, , '
Lai at1 oppliildde well lntrmier(Le.Ctunsy,pate..Yurlan-e:biectfou,,ctcf ilk:Iowa 7d Antount of disinfectant lased: '
3:Well u.kk(checkwcll use): - !
Watcr.Stipply Well; 70.Scaling Inatceiulsuscd(cheer:alt that apply): : . .
Cl cmitittal - ❑hltinisipoUPttblic, ❑Neat Cement Grout :
iV . 60 Bentonite Chips or Pellets
DCreothcnnaal(He:gin/Cooling Srrppiy) ❑Rcsidcntial Water Supply(tangle) ❑Sand Cement Grout I' Cl Dry Clay
❑htdiisUial(Comn ereial ❑Residential Water Supply-(slian d). El Coitcn to Grout• • j ❑Drill CUuiugs
.01nigatiou . . DISpecialty Grout ❑Gravel
Nan-Water Supply Well; - - - -- ' ❑Bentonite Slurry El Other(explain under 7g)
t9Maltitoting . . ❑Recovriy. . . • ..
Injection Well: - ,7f.For each material selected above provide antonat of:materials used:
❑Aquifer Recharge •OGriiundn:rler Remediatiom 1
❑Agmfer Storage and Recovery ❑Salinity Barrier -
❑Aquifer Test ❑Stonst aterDniitioge
Bentonite.:251b ,Wtr:gal. l
❑Egscriuien it Tedtuo[ogy i7Subsidetxi Cororol 7g.Provides brief description Of the abandonment procedure:
❑Geothemral(Closed Loop) ❑Tracer • '
Pulled.temporary well [and b$pkfi 3Ted?,bpreha w/ hydrated
ClGeothemxil(Heating/CoalingReturn) . ❑Othertesplain under 7R) • .. �r @�, .ate a
bentonite chips. I' aa r
d.Date.vvrll(s)abandoned: 12-18-23 ,1AfV 1 v [OZ4
isWc }+ _ UR32
lllocntiou: lntor;;�.:i�;t�y,^:g
Burress Residence
FacilitylThsnerName Facility IDS(ifapplicabte) .8..CettMention:
•
89 Rattlesnake Branch Rd. Canton, NC 28716 "{� _ �_(+JlhwG+ 12/27/2023
' Physical Address.City.and Zip Sip-more,ori_..it!cd 2 cf'Cnutn:toror Well O t r Das:
Haywood. fly signing this farm; 1 hereby certify!that the trellis/was(were)abandoned toi
County' PaneclIdmiu1icitiau No.(PIN) aezardace with FM CLIC0'CAlQ9.or2C.0200aPell•eatislrndlorrSfiintkitds
• and that a copyofthis necnrd htas beeii'provideda'o the well owner.
56.Latitude and longitude in dcgrecstminutes(seconds or•decim_ al degrees: i,
Owen fitd,one ktotoitg is dun icon 9.Site diagrams or additional well details:
•
You way use the back of this page to:provide additional well site details or well
N - W abandonment details. You may also attach additional pages if necessary.
t"ONSTReIC6rON.DFTABt.S OF WELLI:S)BEING ABANDONED SURMTITAI.INSTRUCTIONS
:lusters nc11 coax:f action ratwrd(s)1f dviaitable. Fen'multiple injection' nun•uwter supply '
wt11rONLY with the urn a rsmtcdojr atmr[lormiern.jou cansubnift onewn2 t0a,For All 3Vc1Ict- Submit this folmi within 30 days of completion-of well
abandonment to the fallowing; �'
.6s.Weil m i11'55 1.
Division of WaterRtsourct5,Informatiou'Procusing Unit,
• t o.5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
6h.Total ell depth: • I
Lob.For inieetiun Wells: in addition to settling the form'to theaddrss in l0a
fie.Borehole diatuetct:2.25 an.) above,also submit one copy of this.fomr aithiii 30'days of completion of well
aba ntlonnient to the following: II
Division of Witter Resources,Underground injection Control Pnigratn.
ftl.Water Cm!below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27619-1636
6aUrttce grin 1 (if known): 0 5 ( ) lec.For Water.Surinlv'fi.trtkction1WVIells: In addition to sending the loon to
1~length( tite addresses) above; also submit one copy of this fort within 30 days of
completion of well abandonment to the!county health depurinient of the calmly
6f Inner easing/tithing-length(if loeawn): (ft.) where aEttlndancd,
6g.Sawn length(If!moil n);10 a(ft.)
Bann GW-30 North Carotin Department orEnvirounncrit ant Natural Resources-Division of Water Reso1 I s Revised August 2013