Orange_Well Abandonment_20240318 (2)

WELL ABANDONMENT RECORD For Internal UseONLY.
This form can be used for single or ntulliple hells
1.Well Cnntr•armr Information: \1 E1 1. ABANDONMENT DETAILS
Stefan Smith ?a.Number of wells being abandoned: 1
Well Coorractot Nang rot well o%im ptscoulh alund:uuu�well on hKdrt prttpcm r hW' r woplr ogv,+r,a „r .r,a-role, swppA .ells Os'LI ..,h tk .
cv)rxttrnab.xr.rlyakhwnrrrrx,ara s.ur�MlWrrf,xrr/amen
3576A
NCWcllCaramcuuCerti"ionNuutbcr 7h.Approximate%rtlutrrcafwaterrrrmainint;tit
srrllfsr?5 rtal.t
SAEDACCO FORµ ATFR St PPl 1 \\1 1 I.�ONI l:
Conwatn Naar -c.1Ilie of disinfectant Used: _
2.µ'ell Cwstatietiun Prettitit N
Lei ..7 grkahlr arll;rrmrr.c are.('wM.)rule.lartunre lnna(mm.etr.r tl•bwrwn
74L Amount of disinfrrtanl uss•d:
J.µell use(check%sell Usel:
Water Supplti Nell: 7e.Sealing materials used(rbrc-le all that apply):
OAgncuhural ❑Munietpal,Puhlrc O Neu Cement 0"a M Benionnc Chips or Pellets
l3ticorhemul(Hcanniz.'Cooling S+gtph 1 ❑krstdconal Water Strpph'tsinglel O Sand Cernew Gturn ❑ Dn(la\
OlrtdusinallComnteroal FIR:•ctdcrnral WaterSjmh tsh;+ncd) O Concrete Gran ❑ DnllCulhngs
❑Inn txtu ❑ Specialty Grout ❑Gra%el
Non-Water Supply Well: ❑Belvo lte Slum a Other lexplain under'g)
I9Mon uonng ❑R.l'U%Cn
Injection Wen; 7f,For each material vieeted ahoce,ptoride ammuut of materials ostd:
❑Aquifer Recharge OGroundualcr kentedtauon
OAqutfer Storage arrd Reccn to ❑Salmin (lamer
Bentonite.:331b ,Wtr:gal.
OAgmfer 7'esl OStonmy:nrr t)rmru+ge —�
OF-\penmeNal Techoologx OSubullenrce Corttrul 7g•Pru%ide a brief description of tlx abandonment prwcedurr:
OGeolhenrial IClosed Loop OTracer
OGeothemtallHeauo �Coolin Return) OOttter(ex Pour in under' 1 _
i IZ&ai x1
4.Date ttran(a)abamMnted: 3/7/2 4
-rr •t S �n�.
s,.Wen loeatian:
New Hope Market
JG URN
Facilvh,On n:t Natrrc Facility IDM lif�plieabkl S.Crnilirati%wr; e�'
6117 NC-86 Chapel Hill, NC 27514 � 3/11/2024
Phy sical Address.Cud,and Zip C' tern Certified Wetl('onnacmr or UVetl Owner Date
Orange _ Ifn myni ng(his farm, 1 hereby cir"A-dMif the wetlfs)was(warts cartartkrned of
Caesar Pared leleatific tion No.(PIN) acconlarx a with lJ.•t M'4('nr.0100 or x-.0.V0 lr eanstrt(rn,rn..r„n<>r n/r
and rhea a(npv of this reword Isles been provi&dto*e weft own,-r
5h.lattitude and longitude in rlegrrcrrminutcniscct+nds or decimal degrees:
'tl"ell f0d mice Lit long 9.Site diagram or additional well detaft
You ilea the the bad,of this page to pro%ide additional well site details or%sell
35.993458 T 79.072137 W abatiomntent details. You tn;n also attach asldntxttnal pages if necessan
CONSTRUCTION DETALI.S OF W FUAS)BEING ABANDONED SUBMtTTAt.INSTRUCTIONS
.lrtuelr rr!!canrtrrrernm rrcnrdrsr t7 w,atica(rk. hies multiple rnlecnan tw wr -vluw%uptihy -
xe•11,r(L�f.Y rvth the+r comtrew7kur,ahamhrurtmr.t!m run.whmil;orr.N�rnr. MA. For All We 6: Submit Ihrs form utthnn +0 days of cemnpletnon of%%'ell
6a.Wed IDae•
MW-6A ki dooniens m the folloning
Ihsisiru of Water Resources,Information Pn+cesting Unit.
6h,Total well depth-. 30.6 (R.) 1617!Hail Ser%ice Center,Raleigh.N( 27699-1617
lob.For Infection Wills: to addit►art to sending the fora to the address lit Ilia
abme.also subum one cola of this fonn urthin 10 days of completion of%%ell
(w.Iktrehrdc diameter.2 (in.l abandonntent to the lolklurr+e
Di%isiao of Water Rrsourees,I ndcrgntuad InjeeNun CImIn1I Program.
6d.W'ater lesrf hck%w grow ad wrfan: 0 ft.) 1636 Mail Scr%icc Center,Raleigh.Nf'276tr)-1636
Ilk-.For Water Sumnh A InircNi *Rs: In addition to sending the fonn to
6c.Outer casing fen-,th Iif Imownl: (h•) the address(est above. also subnnt one cop} of this fomt %whin III days of
completion of%yell abandmuncm to the cotes% health depanmera of the county
6f.toner casing,+tul„og lengthOf kwaw n 1: Ift.) %%here att:ndoncel
(-g.Screen length 1if know n 1: (ft.)
F6nnGW-art Aap+et?)1;

,r
WELL ABANDONMENT RECORD Pot ltilcrnill wONIN
This form can be used for sinak of multiple wells
1.µ'ell(nntractnr Infltnnation: µ F.Ll.AflAVIH1NMENT DETAILS
Stefan Smith ?a.Number of wells beitip abandoned: 5
W01 Coisractot Name bur uelI u%iwi pawit"ahottido"well un low4ger propt:r%I F„r mulopk aqr,t,.,. " w,n-H.rc •u;Yrv, O.x'l.l .rd, ?7k• „u+a
c•hnirrtta'fMM ubarahaiirxtiA.I.,a i c9r,iilwiA„nr h,rm.
3576A
n Nsnttcr 7h.Approximate,alone of water raMniulug in WdRsl?4
N('Well CnigtactorCertificalir lltal l
SAEDACCO FOR W ATF.R S UPPI N µ'F L I S ONLY:
Con>oea>Namc 7t Type tit drunfectant used:
2.Well Construction Permit M:
„f i, a<9..own:, i r I ':aM..QGAe.Ian a IMealam,
741.Ammovaf of tElsiafcYYant U1lYl:
3.Well nse ichecic w f•{I usel:
Water Supid%Well: 7e.Sealing materials used teheck all rhat apply):
❑Asncniti mil ClhAtniorml Public ❑ Ncal Cement Cir(nit W BerY(n ag;Chic of Pellets
06enthcmcd IHcanna('oolin_5ripph i ❑kc id trial%kalcr Supph isinele) ❑ Sand Cemew Cicada ❑ Dn f In
❑litdusinalConmicrctal ❑RcstdctataM':acr Gipph Islundl ❑Concrete Gtorn ❑ Droll Callings
❑Ifi lwI1 ❑ Special[)Gruui ❑Gomel
Nos-Water Supph µ'ell: ❑Beotaute Slum U Chhef iexptain udder 7g)
®NiUlalOnII2 ❑kcrut;n
Injectinn Well: ?<Fer each material w ect d ahosc,pins ide amovet of makitals wsd:
❑Agmfer Recharge ❑GmundtYaler Remcdcnton
❑Aquifer Starage and Recosen ❑lalnun Bather
Sentonite.:281b ,Wtr:gal.
❑Aquifer Pest ❑Stomni:ner Uraiiuige --
❑Espaimrnvl TatmobK% ❑Stfisddeme C'oratnl Pnnide a brief description of ilk abandtinmmt procedure.
❑Geothentdal lC'losed L.00pl t_ITracer
Pour
❑ cothenttal(HearinCooling.Rcyumi I]Other(L\pljjjIj utdcf'gI
4.Date%ells,i Abandoned: 3/7/24 2UZ4
Sot.µill Incation: Lri�I ldr•�,1 �
New Hope Market
Focpih fh, ,I+_.„ Facility 111101(ifapplaablo) 8.Cettilkafitm:
6117 NC-86 Chapel Hill, NC 27514 3/11/2024
Ph.steal Addtess.Cad,add Zip ,� ..('¢haft d Well(bntraclM Ot Will OwaCr Dote
Orange 11i .vigoung Nus Jamul, 1 hereby cemfy than the well(s) was iweret ahtui timed in
Coma, I ILt'I kkittfk�rinu No.1PIN) a(conlam a itith/S.4.'vCAC 02C.0100 or 2CC.0:00 Well C'anshttchon,Vruuhtrds
and dial it t e"of this record hen'been p^as'W to the well owner.
fib.Latitude and Longitude in deghxes/minutes/caonds or decimal degrees:
{il„ell1ihl oar Lib Mn I++ulh.in 9.Site diagram or additional well diouiti :
You tim the dh bad,of ibds page to pnn de additional%till site details of Well
35.993724 N 79.072064 µ abandonuteni devils. You nwa also auach addineigal pages if rwccssan.
CONSTRUCTION DETAILS OF W'EMS{BEING ABANDONED SlBM TEAL INSTRUCTIONS
.!(each will evnvhvc$&w ireunbr+q mwhahk, i•ru maniple tW ijfm or tmn-»crier SYpp<i
i elk ONLY with the vaneclAestirafaur rrhnrAlerir.iar can whmuvie k+rm Ilea. For All Wt1h: Subtral thee form %ithin ;0 de\'s of completion of ti'ell
Mi.Well ID/:MR-9
ahardonmcni to the f-Aloiving
Uiiision of µ'otter Rrriturct�.lnformAtioa Prvmniuk Unit.
66.Total well fkpth:
25.8 Ih.l 1617 Nail Senicc(enter,RAleigh.NU 2769)-1617
Wit. Fur Iffikyllos Wdls: In addilbni lu N:IfdIIIL' the iUIIII to elk:ddtrss ul Hta
abode.a6u submil one copN of dos lone %rdrm 11 ;1at s c1 conipletion of hell
fc.&irrhdlle diameter:2 bin.{ ab:ud0nnW1W to the lollottmv
Divisiouof WaterReaoarres,t ndcr,_t,airid Injection Confnil Pon rate.
(pd.W'atcr Lerti beMiw(hound wrface: 4 6 (h) 1636 Mail Senice Center.Raici_h.NC 276"-I W6
lac.For Water Smmih& inieeti(ra Wells: in additr(mi to sending the form to
(.e.Outer casinglenobIiflawnn): ( ) ilk- addfess(es) above. also submit oite cop} of this forgot %ithm to drays of
completkin of%ell abandoaitcut to the couch} hcabh depanniciv of the court"
6f.Inner easiugforbinag length(if Im wlxrc abandoned
awu): (h.)
6r,Sam kftM(Ulmani: Ilk)
Fomi GW-lo North C•aroluri Derunuiciv of Eit,ironnkta ind Notional Resomms-Dh ision of Water Rvutllee, Rc,wed Aa usd VII;