Orange_Well Abandonment_20240318 (3)

WELL ABANDONMENT RECORD For laranif Use ONLY
This form can be used for single or multiple%tits
1.Wier Cnutrartnr Infor•ination: N'F.l.l.ABANDONMENT DCTAILS
Stefan Smith 7L Number of wells beifax abandoed: 1 _
Well Cotrracnot Nante JOJ w.11 iwiier prscrJulh attardomag wen on nrsrlrr property 1 Flv MIF/fi k- IRN110u1 Iw .«W, Ilfer .rkrrn well' rJ%J t ;rh Ow qwl,
('.wow,fJ-ar,IhrUkhWNh'IN,wN"U,,O uJJ-mw h-rpi
3576A
NC WvIlConlactorCenificalion Natrber 71r.Apporixirnate valour of roar rrinainint in,%cllt.l�.,4 I^al.i
SAEDACCO FOR WATER SUPPI l MFt Ls 01-1 1
Coeoanf Name 7c Type of diwnfectant uwd:
2.Well Cou+trvction Pcrnal k: _
wt Xm*e.I.---- hqe,I nor,eft%i it knrlrn
71.Amount if di.inkctanl uvd;
J.Well use tChtcI,well u.cl:
Water Suppl}%%ell; 7c.SCalinl;nurt•nal.u,e•d IChrCI,all;hat Apply).'
❑Agricnhural 0hltmrc11MU'Public ❑ Nat Content Grout M Bersoonae Chips or Pellets
O(cothemtal Iticaung-Vooling Sttp I ❑Rcsidcrhal Water Supply(single) O Send Cement Grout ❑ Dn(la}
❑lidusiruIA'omrixrcial ❑Rmidential Water Stglply(shared) O Concrete Gran ❑ DWI Culluip
Olin Mill O Specialh Groul ❑Gra%el
Ne♦Water Supply Wen: ❑Belvonrte Slum ❑Other(explain wrier 7g)
®1Notalonli ❑Rccoven
ujectinn Well: ?<For each material w1ccu•4l ahi%t'.►loin We am ont of materials ewlld:
OAquokr Recharge OGnwndtvarer Remediauon
❑Aquifer Storage and Recmen ❑Saluuh Namcr
Sentonite.:261b ,Wtr:gal.
OAgmfer'fesl OSlomraala Drainage —.
OEspenmeral Technology ❑Subsidence Control
?r.Prni idr j brief dr.ariptian of the abaodmnrirnt pnict•dotr:
❑Geothermal iClosed Loupi OTracer
►►Geothermal(Ne:rnnl,(oohiw Return) 110ft i ICE Pour ain under 7 t —
4.Date trcWnlabandrrncrl: 3/7/24
5a.Well location:
tR 20�4
New Hope Market
R.Crnilicatitm: "'�• ?r-- y
t":><drh(lnrxr Nalttc Fxilih IDM(ifatJplicabkl t -'�M►�JI 1 tea.
6117 NC-86 Chapel Hill, NC 27514 A J 3/12/2024
Ph,sical.Address.Cnv,and Zip � �Iwr--.Centrwd Wed Colmawtr or Well ArMK Oak
Orange B) .rigsuW thJs JFMiw, I hereby cemfy that the-fi(s) was(were,abuwbard its
t'iuoa% I J1ieI Isk idifk:1um No IPI,i oc'corrhowe wide 114.►'CAC 02C.0100 or X 0200 Well CtJnshvi-11un,9arulttnLs
and that a cnni of this record hat beets prm-ided to the well ouster.
5h.Latitude and longitude in degreewtrminutcvcec•Itnd%or decimal dtjtrea:
..11 a el➢fvld one Lit lroi.1.,un­1V I 9.Site diagram or additional well dnyails:
35.993920 A 79.072065 1\ You out use the bad,of this page to prmide additional sell site details or cell
_ abludunnrent details. You tan tale attach additwial pages if nrcessim
CONSTRIICI11O\ lot: \il-S OF W IEWS►BEING ABANDONED SUBMITTAL INSTRUCTIONS
.Rhki;yell cvlrarJna .'"I I a,wha"k. lvv m,irr,rre oleo•ill",ru'f M "I" ,l.ppir
wells ONLI'oaf-Jlk whmiJ core,plem Ina. For A11 %LAv Subsoil this form %ithm ;0 days of completion of%yell
69.Wee Ia1!:
114101-10 abmidounicni to tttc following
Diii%ion of Water Resource•+.Inforntafion Proct-ving Unit,
6b.TWA*rtl depth: 25.5 (n.) 1617 Anil Senice Center.Raleigh.N('276T)-1617
till-. Fit Imixtioa Wells: [n addit►cin to sending the form to the address to I(la
abuw% ;&lei suborn one copy of flits form%%ithin Y1 days of eumpletioo of%ell
fie.HnrClu-li'di;IrnrltY:2. (ie.) abludontnew io the lollo%uig
(h l Misloo of\Rater Reviurco,l nnlrrYtnntud Injection Ceea»l h+�ram.
hd.\\atrr Ici t l helm _I iurNl srirfacc: 4 5 1636 Mail Se•nice Center,Raleigh.N('276"-1636
J.c.()un•rcasingle h lif laortnl: (ff.) Inc.For water Ssonnh A Inh•ctiole Wells: In addition to sending the form to
the addwweal Axne. also submit one copy of this form Ailhin 10 (lays of
completion of iidl abandonment to the comer health department of the county
elf.Irev earinR �R W larwe) (fi.l %ticrc abandrined
6�scataee.hni�p(r ltwir.y: (ft.)
FornGW-10 Noah Cawlitu Depanuterr of En,trutime i old N:aural Rt!wuwcs-Dhmosof WxwrRokVisces Re•%rsed August:I)1 i