Surry_Well Abandonment_20240116

. 1 1• WELL ABANDONNIENT RECORD For Imornal.liso ONLY;.
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ThiS.fetnicatibe used ferSinkle o rmultipie Wells:
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1.'WeltContrieitithrfOrrnation: • .
WELL.ABANDONIUENTEIETAIL8
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John Eisenman .. • . '7a,Number of wells being abandoned:— •
WelIOMUitlirN'anie.(ar uell.n"wrieiPznieiikl}:atiiiiiiiswii silifsilleilifepay) Far -ifallapla atletwour co etin-ideiter ..$itiipt),- wells- ONLY i;e1tb rliiii sdni0.
1.11Y Of Mkt Ir'6114417d1,"
4439A
7h.Approxiitrati•vidinino of ii.atm Itlinainingla nr11(49 .(014
NC Won OimiraOlor Con ifitioti Nituhci
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FOR II.VATF.:R.SOPPIIN WitI.LSiONLY:..
SAEDACCO
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C4naminyNanie . . . .
7C,TypO Oldish:fel:taint used: I .
2:Wdl.Coustruction Permit 0: - •
list all inifavNe.win plank/10.e,4,1.1y,Sia:te,ilife brjedifia,gle,fr ft-karma
7d:Amount oldiSliffeetant used:,' • .
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3.W41tifse(cinecloVeil,orie): • . , .
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• - Water Supply Well: 74.Sealing:initetials•died.(ilieek"all that apply):
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bAgriettlitital• itiMitiONIMut*. IR'Neat Ceinecirgt* Li Benronite.CIIIPS of Pellets. .
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Oaceilicenial(Heating/cooling Suppl ) Ogcsideprial Water'Supply(single) Cl Sand Cement Grout '. •0•bty-Clay
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0 Industrial/Commercial 0Residential:WoteriSupply(shared) -1:1 IP4Pc''0e2.01'lli • _0 Drill qttin •
. • • ,Ohrigation_ .. • . . ' -*O..4ciaj1 OrPtit • • ''d.Gravel . •
•
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• Non-Water 8uppty Well: " • " - 0 jElentottite Shirty 0'biller(explain under 7g),
•
11311V1Millorine . ORecovety .
Injection Weil: ' • 7f.For.each material selected aboVe,Provide amount-of materials used: •
04linifiltO* : • OCrOundincer-RituOdiation
.• . .. . Neat CeM.:941b 04tr:7gal: Sand Cem.:lb ,Wtt:gal.
liAnnifer Shinagazind Oft..-Over.3,!, 1:18alinitr13:irrior
• . 13Annif4.t:St. 17licinunitorDrinnago..
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' . Eltaperititernal Techuotogy. pStibsiclencegpiaml '7g.Perilleten Brief.tkleription of ihe'aligirdonmeitt proeedure:
OGeothennat(close4.1..pop) LT.Tracer -
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pull well from borehole then pump portland through tremie
CIGeotheirmai(Hmtinkeoline.Return) 00ther(eXplain under 7g)
. ' pipe from bottom of hole to surface
. •
4.'Drate vrelkilithiindOnetii I.-4,2,1 •_ ' : '.:-.:•q--if-..'e..::2',1 re'-'er',.,
• '''t---‘...1"1.--i; r7 3 ,.' - . '
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S.a.Well ruegiion: -
. . JAN 1 l'; 2n24
. . . • •_, • •
8:certillentiont inf''''''.'il,ri 73.----- ; i; •
racilinithyncrNIIIIiC FMittlY IralirilOOlicalitC) . . .4.1.1...e..........„{ .;.z.,...x.7,..,.....2
DWC:i300
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710 Piedmont Triad West Drive Mount Airy Airy, 27030 . : ''''q!' ----;----7---- -.'--.-.=,--------7- 1/8/2024
PhysiOal Address.City:and Zip . ftttllel.,!...5.V& -filgir,ciiii714*,,,i17:?:k.0?„,75,,FiZt7-- - Liaie
''' ' ',.. ,29.,*(4,1-.1. •C.";-. i!":57-4.,....+7...-g.-Y, :;i,..--2, -
Sur ry . • , . • 'By...signak.g iht s,........" ,,,::••:,-:•7• •:.1..1.0 Our the irellf,$) 14'as(irgre).abaurianc4.in .
ParqlpcniireCitiinilski,WIN) arxvi-tkiniv ivila 1-. 1 ict'Ad 62e!0,100 or 2C.0200-11ell.a.aidiatellori Slanilai4s
• - . • - .dasdllfat acopy of this.rerprii has beeapraviciatiplirefwv#.otsaer.-.•
.5b,1,,arilnde and longitudihiciegiteStmitnites/teiori q Soi"deelintil.degives: .• I
pfle.11rpotti,ono Iiiiiiiiiigii;siifficiono ' "9..Sito diagram or additional well details:
. -You.tuay:iie lhie.baelt ref this page,to*.iii&ide.additional. 11•Siteldetnils or well
- N ' • - . . • W :abandotune tit details. You.tuaV alseAlach addiiional pageg•if neetsiary.
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CONAT1111C-IION DETA/LN OF WELL(S)11E1NC ABANDONED ..8t1BMITTA1.•INSTRITCTIO?iS ' ..
Actatir irfl.euuurrolou.n;Eurdiv g'(iiihrali I e...Pikr irriiffikb bliolithe fir min•ituier yispply
ti.vjV.004'*Jill 10.0ametoiutrodion4thipidom4o1..-j,titi L'Illi;61On 41Wfirittl;• " ,1041.Flit'.All Weiii: Submit-this:fano'Within"30 da c of completion'of well
6ii.'Nell llii-TMW-3 • • • obandournOnt tattle foiloWing: I,
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Division of Water.Resonrcts,•Infortnation-Prnees.sing.11nit,
6hi•Total well depth: 40 (ft.) 1617 NIA e•Centet;Raleigh.NC 27690-1617
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Illb,For trileetkitt Wells: hi additiotflo sending the final,to the address In Ehn
• nbcrkt.also submit one...tepy of this:'filanc within 30'*daysi of enitoiletion of well
6e:•Borettole'dianieten 2 (n.). • . al:MirlounVnt tathe,fonriwing: I .
.Dhisiott of Water-Resoureoilhiderground Injection Control Program,641.Water tevel.belOw.gi*und surface: 33 •. (ft) •163.6 Mail Seniciqiiiii,Raleigh,NC 27659:1636
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10e.For Water Supnh'&roit. tioroWells: In.addition;to sending the form to
6e.Outer casing length(if!mown); (ft.)
. the iiddresS(eS) above; also submit One CO3 of this ton Within 3D days of
completion of well.aboridcounent Co the county health department of the county
Where abandoned,
6E Inif&easing/tuhing length(If lacown):.39 . (ft.)
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6g.Screed length(if known):10. (ft.)
Form OW-jo Nenlitareline DeparnneFd efEnviroonicaand Nani6111esouz,tcs-Divisionef Water Ilcsoifices Revised Aiigta?i 2013
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WELL ABANDONNLEN.T RECORD ForintenuI-Ut ONLY;.
This feint can lie used for sitkk or multiple wels'
I.Well Caatr.Icter'Iuforniation: • WELL ABANDONMENT DETAILS '
. John Eiseman- , 7a.Number of wells heing airimda I
nm cd: 1
( p.. } n114%%eI1onlistlierpicpeny) For rufipie fnrerrtat ur'raurr-11titreJ sire . adults' ONLY win the sriune
lYellCutgeaemrNatm: Orttellntt't�r 'l�iln.'fll::di�ald." h�
c+etasriucocei,'tbnrriltiriiracrnit;1rtu tan sulvn f arefrrrm,
4439A 1
NC WoD onlmaorC�-ilitt ikon Nun ict 7h.Approximate tailgate of them Matting in-�i'ell(r)4 (gill)
it
SPEDACCo . F.OR-WA'1'FR.SUPPIEAWEIISONiY::
Company Name 75.Ttgte nf ditinfee MnYuzeti:- I • .
2:Welt Construction Permit t:L• ,
LEVt all upppilyi a imitl jai uijie(l.xt Ceouht 51ate;Pi ido e.irjrriai;rh;i.iifkploo
7d.Amount of disinfectant used .
1Wdl use(&Ueekl ell,ule): , -,
' Water Suppy Well: 7,e.Scaling matciinl •ttsed(checl-'ail that apply):
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17Agricidtuiat • L7MtinicipalVPublic:,• • Gd'Neat Cement.Grout ❑ 9entonftc Chips orPellets.
IlGcotitcrned.(licatinglCooling Supply) bricsidcnti:it Water.Supply(single) ❑Sau
d Central Gat ut ❑.Dry•Clays
❑Industrial/Commercial pRcsidetui t'Wtiter•.Suppiy:(siutted)., ❑Cotietete:Grout CIDrill.Cullinbs•
• - .D(rtibtitioa 0 Specials}.Grout { .0 Gaye!
• Non-Water Suppl}•Well: — • ,'©Bentonite Surly •CI'Other(explain under Tgj.
•
®M:Dilloriiig . . ❑Recotety '
. injeetinn W tt: - - 7f.For each material selected above,pnwlde atnouot�o_f.mite-vials ttsed:•
• . ❑Ai1uifer'Rechate ❑GniundWaterRetiieihutioit Neat Cem.:941b ,Wtr:7ga1 Sand Cem.:lb ,Wtr:gal.
IflAguifer Storage alit Rctitweny ❑S diiiityflatrier
❑Agitlfer.T st ❑Stonnuater Drainage,-
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❑Espettmenlal Technoloev ❑Subsidei.Ceolml
7g.Frnt iilc a brief description of t i c abaadnnmrnt prt►ttitlpme
- EIGeothennat(Closed Loo))) C1Ttacer
pull well from borehole then pump portland through tremie
OGeothemial(HotitteaCoolin Return) ClOthertenilain under 7g)
. pipe from bottom of holeito surface
3,°Rate ttell(s)abandoned:`179-24 i F.E� ,� \y,i.,,,.5
{a.W.CII ltieatitln: 11 Q\ i 2021
Facilii'ttytm-Nttirc • Facili i lDb.(i1 i licablc) :3.CertIficatioy: ; !` �r�
} �p 1Ric viri,r it •>g?:?'.:; h F,5s.
710 Piedmont Triad West Drive Mount Airy, 27030 ---;-� r�8/2024
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Ph;'sicdlAdtlress.Citp:and Zip • Si.Grttti a :�s;,4epbart'r:'tLi 4:u. —c''?...•:,,mic: Dale
Surry •- lit+•siguing_thts ._,•_,:;.µ'?. •::.:t•�.-tha th t the irehl(s) uds(were)abandoned ire
Legtay•• Perch Idetuifi ltio NO.(FJN) tics'oida ce ivihi 104 CAC 620.010 or 3C.0200(I d!Coirsfi uciort Shard rrc(s
mitt that g COpp(JAWS' liar beeit prOyided w the tvel Dander. '
Sb:I.atittadeand longitude in dogkosrntitisitestsceondss'or.lccinl;il.clegrces: - 1
' (tfts•ttr fold;(ktm litlloIig iss,tiii0p1) . 9..Site(pagan')or additional-i ell details: '
You may.iise the,bacl:of this page to proOde additional sell site:details•or:will
• N W •h udonntentdhtills:•You ably alga iutaahadditional pages ifltecessaty. ..
CONSTRIIL"Pit)N DETAILS OF WEL1_(S)BEING:ABANDONED • tIBAttTr ki,iNSTRTiCTiONS j'
,ltfrid,tr_'e.,0 rusttrurlOra.rrcvrd(sl If,au i1alle. .1rir miilnple irtJ'C�ifiit,f di O'JA:1tarlu-.tisj flip
ivegi ONLY ti ii i the irata ar,st trtvrimrrlahnrtrlOrn term.je rl O suAltrit aliforirc, ' - .10a:Frir All Wells: Submit this Cont within 30 days'of completion of well
6u.Well Ql€tt
TMw-2 abanatiumcnt to the following
.Division-of WaterResourefs,Infotmution Preeessing.Urilt,
1617 Mail Sci'ire lte itei+,Raleigh.NC27699.I617
6h.Total well depth: 45 (ft.)
lob:Far infection Wells: In additiou.ta sending the fotns to the address En IQa
frc:Borcliolc diitrttcter:2 (in.) .'above also subudt one eopy Of this IItimi ii'illiiit-3()`doys,of t:ornpteiion of Well
• :ibiitidourtteut to the fellow iii g
fed.Water let cl'.hctott 33 .Dhisiou of Water ltcsourris,Underground Lijecttou Contiol Program, •
ground surface: (fr:) t636 Mail Seiricc'Centcr,Raleigh,NC 27699-1IG3G
IOe.For Water Sunnly.5 inertial Wells: In addition to sending the fort to
Ge.Outer casing length(if Imoit it); (ft.) tile.address(es)•above; also submit'one copy of fits foam Within.30 days-of
completion.of well abandonment coolie county health depatiment of the county
Witte abandoned, i.
6E Inner eayingItuhiog length(ifiaiuwn): 35 , (ft,) • - .
6g.Screen length(If known):10 _IN
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Forst GW-30 Nonli Cawtlm Department dl'Enviniument.ani Natu:at nssotuces-Dis lsionof Water ittsoutis Revised August 20 t_i
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" .WELL AIAA1ND.ONNIENT RECORD
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For.lirternal Usc ONLY:. • 1
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This fornicaribe used.fer Singe:pr turilliple.*Iln A
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• 1.Well.Ctintraelar•inforinatiOn: WELLABANDONNIRNT DETAILS • '
John .Eisenman . 7a,islinither of wells being abandaImll : 1 .
... ,. .. , . . . . .. . . ... . . . . . . _.
Wel1cortraelorNarthe(or%tenon.*innsettalli.ahnirkinlig weti On likuher preperty) Fa r- andaple. alletgaa or mnmilfiter .sirpply wills-- ONLY withike' same
marrreCotmiabrivdmivienf;-Rio cjia salm of aaelbrar,-
4439A '
'Di.ApproilinOtr vnlunte of*atm'Laialining in Well(S)0 (gni)
i.te Welt Cantrator Qin Mon int thinker i' I • * • *I *
SAEDACCO
. FOR WATER SUPPIAWELISIOMIX:..
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Company Name 7c,Tnie rittlishtfeetant DSO:. II
e ,
l'Well•Construction Permit#:, , •
I,2 I all'apyk:Ole 1411 itvrani,4'(4,Coaate,.pare,Vadimte.,.brjectioto,ck.) ,
7iL Amount of:disinfectant used:I .
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3:W.ell use.(eireckWell.usi:):
Water Supply Well: • 7c.Scalinginatetinls•nied.(ehtelt•all that apply):
: .
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bAgricirltaral. .. 01.4tinieiNliPublic, -bil-NaitteMent.Grout 0 l3entorlite,chiPS et:Pellets
•' • ,
• ' O .Icollicrmal(Hcadrke,00ling Supply) tOcskinottil WatcrAipply(single) . 0 Sandca,-011:64:!t- , El Dry
• Ellodustrialtommacial• IDResidletaia1Water,gupply(shared), . 0 Oil'cTe!0:Grou.1 0 brill Caning's-
.
Elkin:Rion . • •• .0-. 00114.01P41 , 0:Gravel; . ... .
,._ - ___ , . •
lgtm-Water Supply W __
eld: • • • • " ,0 Bentoui(eltirty - I - • —
El Other(explain under 7g). ' •
11§MertilOrine, . OttecoVety . i
:Injection Well: . , - •7f.For each materhil selected-above,!provide'amount of.nuiteriats used:
OArprifer Recharge 0Gretnitinatir Rentedintinn Neat Cem.:941b ,Wtr:7/gall. . .Sand Cem::lb. ,Wtr:gal. •, .... ... ' ' " •-• • ' "
bAquifer Storage andlpieebveiit. LISallnitS,Darrier . .
. . ClAiinifeI-TO -0$toninvincr brantage
• Otxperititeutaltechnotoev EiSubsideno.:.Conital 7g.Provided litieflIelei-iption of the abandonment procedure:
0Geothernial(closed-Loop) 0Tracet
' . ... ..... • 'pull well from borehole then pump portland through tremie
0Geotheittual(HQtion/Coating Return) 00ther(molain under 7g)
pipe from bottol of hole to surface
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4.'D4feWeg(i).aiiandonCiti 1-4-24 • - p
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5a.Well liteatinii:
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. • JAN 1 6 •i024 .
.. r.pitifioiio-ii:
IracilitiKhytigNitotu 'Wilily 1.134(ifiipPlicabic)
1rif3;m2:-':io.ri P..-.::::-c-:::',74-„,!r-2 Lliti •
710 Piedmont Triad West Drive, Mount Airy 27030
PhysiCal.A4dross.City...and Zip SitItult 4<•.'.:Ii-'.:..trAt:r.:r.i,reck.i."..49.1.1-_-V:s71!; '.:1.-:'-..nvt :' . ale
,.. 21-1Y•(.-.41.-.4 .C-....4-e-..7...-7e..--z
Surry • EIV,sigifing,ilus•.,..-4.. .. 4%.:.:..--m-:.fi:.-,:z.Vi.fr:lhat the well(s)twqs(were). in
conety. P4feci Nesdiripitl4o,(PIN) 'aiccorridacc via?114.NC4C 62e.0100 or 2C.0200 Well ecis,sitracliowSlaaelart4
. . . .and lhay a'copy of lime record has lieen:pnnidcii(o are WO onver.... '
5h;Latitude and longitude in degrees/Minutes/R*000s oeiteeinuill degrees: 1, • '
•
oven ri..td,inte'latilinits;sliiri:*nti. • . ' • I I 9.Site dingram.or additional Well tlettalls:
W You Mal'.tiSe tlie.back:of thin page to'titaid4.additional Well Site.details or well
. . 'aliandonnterademits: YOu may aLSO attach additional pages if nectsiaty_ '
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CONSTRUCTION DETAILS OF'WELLIS)BEING ABANIIONED .SUISMITTAL INSTRUCTIONS
:Work yfell coriviractian tee-twills)11,akitiaabfg. .For mplahle atjeclidu oi tion.wdier'xi:pp!):
Ite1g.o4yir likt ii.m5 Satilecoittrogron,i6Orgoitr:Joit.pitil cyg.sirlutra kitw.,ST. - 10a: Fair All ViClls: Submit.this fcirei within 30 days of.completion of well
abandOnmeot la'die fallowing: :
6a..Well Iligir Twq-1.
Division of Water Resintrets,Igformution'Processing.Unit,
• .1617 Mail kei-vice-Center,Raleigh,Ne27699-1617
• 6b.l'atal well depth: 45 . (ft.) • • • •• • • •
10h:FOr litilt4liOn_Wells: In additien-to sending the tint to the Oatass:hi 10a
above:-also submit one Copy of this'form width]30I days of touniletion of well
• 6i,florehold ilia:niter:2 (iii.). UbirtidmintOtit to the following: I:
Division of'Witter-ReseurciN,Underground hijection Control Program,
(id.ltikr level below ground girfacei 33 (ft.)
:1636 Mail Service tctOrin,ItileIgh,NC 274994636
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10c.For Water 5nrily&bilectfonIWells: In addition to sending the form ib
Ge.Outer casing len011(if brown): (ft.)
the adlitesS(esi above:-also submit one copy•of this foun*Within 30 days of
carttpletion of well abanderunent to the county health depannient of the county
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Where abandoned, '. • 61.Inner easing/tubing length(if Imown): 35 (ft.)
6g.Scr&tr length(If known):1° 09
Form PW-j0 Non Ittatrotim Pepartnrai SfEtwiroonunt-and Nalurallicsour,ces-Divisionor Watuft%sollocc s Revised Attgast 2013
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