Wake_Well Abandonment_20240318 (8)

WELL ABANDONMENT RECORD FoTIrairrrdl Use UNLY
This forn can tk iiwd for sirtakt,of multit+k i+cils
1.Well Contractor Information: W'F.LI.ABANDONMENT DF:TAIi 5
Scott Hunt, Jr 7a.Number of v%dix being abandoned: 1
tt'cll l'milaclof Name WI well oniiif p:rwm;ilJ)AxiMufa:ig wrll.ln Ins lief prop.m i r:•, Wafo/•'. rn;rtJ,na .k 'A-I-.,.rrrI f,:JJ .rf+s D.VLY wati roar
,v m,rew ri,M Uf•.j*kW/Ww 1.4v r(00'.HIV.Irr,.ufr l,r,r,
4561-A
NC A'01 CnNrtctnt-CCnirkilion NuvbcT 7b.Appniximate wilume of vtater remaining in%eBIN: igal.)
SAHDACCO FOR W ATF.R SIMP1.1'\\ELLS ON 1.1':
Coatpaw+Nai w -r. I c pe of th'in(eetant uwd: —
a Wdl Cot»trat'tian Permit M:,
Lau al (4'ri.:Nr.f.t.r.,vah..k&-.l anwav ImnJlom e)t.i if AN.
'd. �nnru.rt nt di.infcclant a+cA:
3.Wtll ux(check Hell use):
W ater Snpld% Well: 7r.Scaling materi.l,u.rd i chat I.Al thet apph):
OAgricnkutal 7Atu mctpalTi"I: M I*eat Ccmeru(RWI f-I Rcnlonite Chilr nr PL-Wis
❑(;nithernul(Hrrtin)+('nob%,Srtpplt f ❑i1cMd-ittial[Valet Suppit isinplci ❑ Sand Central Qum ❑ Dn CU%
❑lydnsrn:d-Comnwrcivil ❑Kc-,kIcralal A'atet Sirpph[shared) ❑Crnrcrete 6"It ❑ Drill Cutttup
Dltti tioit ❑ Spcti-taitr Grout ❑Grastl
NOn-Water Supph W'cll: CI Fknlcnute Slum V I Ctrlxr(Csplarn utiM"rn
XlNlounonnc DFtttu�rn
lnjretinn ell: 7f.Fereach nivi-riA wict•trd ab.r+r.pro+idc rnuwm of mAtfriakaxcd:
❑At(tnt rRcclnargc OGniriodustezRcntediattoo Neat Cem.:94lbslb ,Wtr:5clal. Sand Cem.:lb ,Wtr:gal.
❑Atlutler wraLe and Recoi en Malia% tamer --
OAquiter lest OSk+rmtsatcrUrutwYe Bentonite.:5%lb ,Wtr:gal. type 2 portland Amount:2 gall,
❑Expettntetual TCCIniulog) ❑ ulin-dctice Coritrul
3y Ptio,ide a brief dc•uripturn of the abandunincnt prntt^dan:
1'0cothernutl!Closed i.00pl 0—frdcet
Tremie grout well from bottom to top; no well tag with info
i1C;eothrnial(Heatiniz•Cvolin Rehtrn) i lC�tltt;r(ex in coder^ ) on well was found
4.Dote wrlttslabandnnetk 2-29-24 jE
't 6n�a+-iss r t. G
Sa.Well location:
North White Street Landfill
Factlq)tltti><r�ittfr 1'.�ilin lnd.tl tpp{ic<ibl ) $•Ceni/kalien: a s+
s 1t1ii.�rY.e►:':l . -:.::,K'+r::=.y U M
1226 N. White St, Wake Forest, NC 27587 ,r UWIA3.x7
3/3/2024
Ph.sical Adds,%.Cm,aid Zip :•m a!•s r ::t:.d Well Canrrxhn in WcH O"mr Dak
Wake )it-vgning (&,i finr•ix, 1 hereby certrA-thug the wellfso wnz Itterer dhourkultd in
Coamn I'.n:cl I,t;fartrc:aPita N..tPt'o cxt(xrlisx'e wilk li:l VC.-I 'I)Y' W(Wor Y' 0-'W Wcl!(fxi.drxtAi�u Srr+nrJlrrrfti
tmd thraf a Copy Ol this ret'fwd IAar been prm-uk d k)4-wril e*m r.
Sb. 1 atirmle and liai2irudr is rkgrrrvmirturciLcrmadr orde+rimttl dit$rall:
•.if ncl:I xkJ.cox:kn.k;r!•r,-allwmx: 9.Site diagram or additional will dMall9:
You net+ tut•Illy bact,of this pap IO pro%itk addilivih9l%tell site dewds of"ell
N W' abatdemitent detaib. You may also:stach:r<Witiuiwl paFxs rf mccssan
(ONSTRI("I ION DETAII S OF UTLIASI BEIM: ABANDONED SUBMITTAL INSTRUCTIONS
aq;,i K.'i:li N:..;�llClp At rc,L Wdl rr U,w4h..rl' i—'1.wo;%'e a.Ftr."two ••1+'}'J.i
.it fl,I).4).Y a:ri.,fir a,rar t.,,.,,r,a rrrr.a+•ar.k.arwrrrt vw ca,"hw,r,otr lww 10a. For All \\ell.: 4uhu<tl flits forgo eithm.10 days of compidion of "yell
ba.\!ell ID*:MW-lRRS ibaidennicru in the followmi!
Di%ision of Water Resourcirs.Information Prtrcrxving Unit.
Lb.TutAl well dtyith: 17
1617 Matz Seritiee Crater.Raleigh.NC 2 7699-16 177
Ift.l
Illb.Ftir 1.6mikm Wjclla: In.addiion to seiidirig the funs to floc ;xMtem in loa
atone. atso submit rite.:opt of tins form within .to lass of txuupletion of"ell
etc.Rr..tFitdi diannter;? Iia.) :ttiandurmrcmr to the rolluniaG
Dhisiun ul Wa wi I.ter Reamn, ndvixnound injection Contrul Program.
r.rl.\\ogre Irtirl Mlnw --wound.iirtacr_ 10 tft.) 1636;hail Scrtjee('enter,Raleigh.N('I7699-1636
10c.F1or Water Sotinh & lnketlim Wells: lot addition to w1bding(tie form to
4.c.Outer coxing length(if Imoti m: unknown (ft.) Ilk AddressicY) a v+v. also submit L4* cups of this fomi "ithin it1 days of
.omple-tion of Weil abantlonunent to Ito cotuvv health tkpailaxra of the c(ntrtt♦
unknown whCre alkindancit
L(. lnncrca�tin�tuhin;;icn:,Kh(if hn.Ji.ui: III.)
to,_,.Screen lent ton(if knot+nl:un�OT"n oft.)
Fonn CyW-ati Nanh Carolina tktrttinteix of En%trontrrcnf and Natumf lksowes- Dn rswa of 1i`awr Rcsonrctis Re%is..`d 1agum:+,I t

WELL ABANDON NIENT RECORD For lrumilUsc0Xt-Y
This foslrt c'aa t used for sintat or ill:il(itde%ells
Contractor Inferinstion: WELL ABANDONMENT DF.TAII S
Scott Hunt, Jr 7a.Number of Hilt+beinC shandoned: 1
Well VeNtltacwt Name tot hell o"Ilex l uTmilialh rWado+strg N.L an IIK lie tggvll+I r.r millflrti+ :!r(<+hn,r � # r-�.r C' �I,t'iJf rc'ifi OAL►' �:Iti !lam eWn,.
<nrr.oq.n.w Uti.irkl'JiMl,vrr 1•rN[av.ertvn:r„►k•tiuw
4561-A
7b.Approximate tolnra of"titer remaining in well(sy. wal.)
NC N'cn Contrlciar ConirwAirin Nusdur
SASDACCO FOR W.ATI SUPPLY WF.LI.SON1.1•:
cklnvain Name lc.Typr of didsfectant rued:
L Well Comtructiou Perttllt C,
L+iJ:rt•,�{:.J,fr Jk'P.fai>'J.r.f!4Nlt1. tklk.lrAir[rrK'C lrryrairrritetetr7lrwrvn
7d.Amount i:l di. niccl,lnl ux'd:
3.W01 use(check"ell use):
Water Ctlplih Well: 7r.Sealing ruaterialc uxrd(check all that a(lpl}):
DAgncuhural DMtulicltx&lsublie M Neat ccinclit(in-Hit Fl Rcntonilc Chips or Pellets
❑(ioi)thernlal tHront}+(noun,Sttppls) DResideidial Water Supph is iWIcl D Sand C erinetu Grout ❑ Dn CU%
❑IndusinaP-Comnterrial DRem(kn tal Water Supply(;:hared) D Concrete Grout ❑ Drill Cuflitip
Dtrtigataun ❑ Sixtlall) Grout ❑Cinnel
Non-%%titer Supph Well: 11 Rcntonne Slurry fl C)(lwr tc"plaill utrdcr 'f I
E Molu tC Him,, DRctia�rn
Injection Welt- 7f,For each Inwrl i:A a'lactad ahu+r_lnu+idr-auutwnl of niatrriak used:
DAilodt tRcdtarl;c 13(1nAinduatcrRcutedi;sien Neat Cetn.:94lbslb ,Wtr:5gal. Sand Cem.:lb ,Wtr:gal.
❑Agwlet wtage and Rccrn en Walnuh Barrier
❑Aquiler7esf DSI°rtn"alarUnutm= Sentonite.:5%lb ,Wtr:gal. type 2 portland Amount:4 gall,
DExpertirwitial Ioclr okV ❑sidmi etlee Control Pnl-idea hriaf de,cripbnn of the alrandunmcnt proccdurc:
CJGeotliernlal;Closed Loop► tJTracet
f7tmci(IrernwltH(�lun •Conlin Rehlrn) flt}tlterlex inutldCr7 ) Tremie grout well from bottom to top; no well tag with info
on well was found
1.Dale,"011i)AbanAmed. 2-29-24
52L Well leention:
North White Street Landfill IVl>J R i 8 ��C4
Fxtho(),t,1-r",6ita• I.,xisi.lnfrdavrli;!'kicy $•Ceni/kslirrtt:
s
1226 N. White St, Wake Forest, NC 27587 ,ram' �' .' 3/3/2024
M sical Addr%-A.Crn.and Zip :.sl:al't'a>rrl'kM WUll contcx I'l or Well 01.Rr DOW
Wake R,v gtgutrty ;lust 1nrm, I/tereky ceritify rh[u the wellfrr wax rrerer ahanrkined ur
['auuh P.acat Id.-oidw.•anrn M-(ft�r trrc[irhrrx4•trilh I A VCAC 0.N'.111(.xJ ur_ * 0-'(NY ff ill Crnn.Vrvr4un S&nuAwIx
[trirl thal a cnfn q1 this rerxrrd IAiPv Arran provn eel to Aso urll owner.
SK 1 aritlul.•and tnnl!irude is da�nritilmimtrC�'sernads or diximal degrir.:
I)i%cll to Ill.ow tit.long tk+ulbcviy: 9.Site diagram or additional we II details:
You nia+ ruse die balA of(Iris tinge to pro+i&additional sell site details m+sell
N W' abandotatlrm details. You ma+ also ailaeli a Witiotud pragrs if rkcessrn
UONSTRUCT1ON DCTAII S OF WFLIASI BEING ABANDONED SUBMITTAL IASTRUCT1OWS
MIkir "M aaas!I?K r..,r rra•ai II At uaw&aftk t.0 w#41(! k:ry'rar:u.,,x,mi-o, ar auppii
OTT 0AL►010 4k'+:,+W'2.Nr.+NiA tl!Hr Ah.Vkk`�WNr7N I-W[YM WJgrrt fVle P;rw 10a. For All Welch: Submit Ihts lorul tunhm .10 do s of completion of well
aha tide ntacnl In the followin)t
Division of Water Remmret.%,Information Precruang twit,
1617 Mai Sen to('enter,Rakirb.NC 27699-1617
MP, ToGr)Nell depth: 34 Ifl.)
Intl. bir Inirrtion%Vd ; In acklilion to wndutg the forth to the address in Mal
ibunc_ also subutit aide copy elf ilas filttlt unhm ZI)dais of LonVletion of"ell
Rlirelrrl)c diameter;2 rip.) : undo harm to[lie I-ol unkit;
Dhision of%i Ater Relirurres,Cndergritund InjaYioa Control Pro(tram.
bd.N Ater level Mrin+l --•roved uurface: 10 (ft.) 1636%fail lienier('ewer,Raleigh,NC 27699-1636
Inc.For Wally Suiiltl+ .4 lokg( o Wrib: In Wilton to warding tun form to
nc.Outcrca.inl lcn ah cif Imo"n): unknown Ith) lire wWressits) at+n+c. also stibmir +tie co;v,% of this fArni "ithin (tl (1•dvs of
:oinpk-tion of%ell ah.mdonincrit to the ti itniN lwalllt depanmcnl of Ilse colno%
Unknown "here atiandoncd
i.(. Inner casrn;:•tubin;;IrmKh of larown): lft.Y
tr .lcrtenlcnUtlt(iIkmii+ni:unknown lft.)
r i i U+- � Non Catoliin ikMvin cix ai Env ironowtil and Natural R.wvncs-Dn tswst of Water k[sorcnvi Re%cscd Airgusa Uri 1 U

WELL ABANDONNIENT RECORD Foilnrenuti"scON1.Y
This forth Call be useld few simlie at mullipk»ells
1.Well Cantracmr Information: %'EL.I.ABANDONMENT OFTAIi S
Scott Hunt, Jr _ in,Number of sell.being shandom* 1
w0l Cogiliaaw Nails: wndrw!' ;.a;t.t,., .s .a.+r-,,,.;�.. ,,,;�;•tr cl;, O.\'tY ��#r else•
.'.r,q,thyr.i1.,l,pRdtMvw t,N+tcM+�wMliti.+Mc•p,�lu
4561-A
'h. 1ppnriiin.iie stdunic it(wanv remaining inviell(s): teal.)
N('\\'cl!C'nNrtctnr Ccnificatinn P:xatxi
SAHDACCO FOR\1 43 ER SUPPLY W i LI 5 O!►1.Y:
Ulxv tttl Name 't. 1 i pv(if dlm"lleciant usrd:_
2.Well Construction Permit
:n,•nL<� ,, < , r,nr.'•.+...!1�b2h.J'taM.i,u•�.mrt /1gaViUuq.rJc.+:J�4rwa
?tl. \mount of disirifcctnnl n.cd:
3.%'elt avr(check weal utie):
W atrr S liph Well: 7c.Scaling niatriitnis usavl(check all that apph):
OAgmuhuntl ❑hlunknpATtibhc x Neat Cemcln(Rout 1-1 Rctrlonnc Chip.rt N14-1,
❑finathertnal(HcatiripCoohng Supply) 011midciui:d\Yaicr Suppls mirr_Irs ❑ Sand C ourm Grout ❑ Dn C U%
01 dusinal:Comnrrciil ORcaid:lulal%Valcr Supply tsliarci ❑ Concrete Grout ❑ Drill C'ultrul c
Mitigation ❑ Stxmalo Grout ❑GraicI
Non-W ater Supph Well: f.l fiemonue Slurp I I Cklxr(explain under^p
EMonitonng DRccusrn
Injection Well: 7C For each nian•rial selected shove,Ionnide anrnunt of materiak used:
❑AgtuierRCclbr,-e ❑Gnxindi►.acrRcracibattrni Neat Cem.:941balb ,Ntr:5gal. Sand Cem.:lb ,Wtr:gal.
❑Aguder Storage atd Rc oven ❑Salinity Barrier
OAgeiifec 1'sst DSkirntsialar[}rurwge Bentonite.:S%lb ,Wtr:gal. type 2 portland Amount:8 gall,
DE-4xnincntal Icch ology OSubskknizeC'onintl
7;,Prm'idc a britf dcuriptu+n nf'tht•abando incnt prnccdurc:
rJGmtherntal(Closed Loop► CiTracer
Trasie grout well from bottom to top; no well tag with info
(10cotkk"wl(Hva6ng,,Cooli!S Returni I IC)tik.r(ec in uttrder^.
on well was found
4.Date w'ell(%)aba(tthinetk 2-29-24
Sa.Wen location:
North White Street Landfill Wit
f(.(l'i11t lCatlfill:
F,i,:ilgi-()td nit V:im F.i:•i 1itN In r+if;ippli'<iblc S
1226 N. White St, Wake Forest, NC 27587 t}, CYY�G:yJG� 3/3/2024
M sical Addnxs.Cob.aid Zip :i�i:•:sr a!'=.'er.Jtid W'C11 Coati7t-kit rat Web 01A11rr D ttt
Wake hi,u urtkg dai.lt►rm. t ltenehy cernJt'doev the well(ri wax ivierei ahanckined jot
("aani� tin-CCI I&nu(w.•:nicsti Mo.41"Mi MCoirtAnx4,wtlk 1 A V7';1C0Y'."10d ar'r' IVIM)Well t'<,naruc'I;on Ste n,k,rrfi
t»ul iMir a chin'of this rer'fird ikity been prr,vitletl tc,Ow orrll owner.
Mh. 1 aritilily aitd liuigirude ilk lie�rrcwmitill rt'c:.r.nnd%nr ifiY'itti:rl rliy;nV%:
,it i%J'Ca:kl.ook:hM.img ih yi!iicxxi..: 9.Site diagram or additional well detaflt;:
You ntat ibis'the bacl,of this page to pion i&additional nell sat&-(ads of vs ell
W abaidwuineni de(ails. You ma. also attach additional pagxs if necensx%.
CQN1.TR11('f1O\DE'1 ULN OF A ELIASI BEING ABANDMED Sl'BMiTT,41.fNSTRIT("ON
.ktrk it writ u-wix!<•i+c ire+r:.�u',i',r tt u�,n.,a',tc. t'„�•an7C:!ie alrYc7hu:Ul+xri•watrr aq+ntfi
,1Y'tly().4).Y"idy ttu'raw w vw.,trwri—i,itiuf.tl.MMl7it._toll c•a i m hwd,Cie 1,)f • l0a. For AB Wdk: Stdimnt this forth Nithtn:K) days of compictlon of Nrll
6a.W'ell IDO:MW-ID abandonnicm in the folionine
DhWan of Water Rem onrco,Info rmatiitn Precinkung L•ait,
t►b."f'utal hell depth: 52
1617 Mai Sers ice('cater,Raleigh,NC'2 7699-16 1 7
ifl.l
I11h. Ftir Inicetitin Wdls. In addition to sending the faun to the irAliess in Ula
2
alm
a. also stihutit one ctipy of this fimti within 4)days of ctmlplrlion of Well
bc.1hr MlNtic dianx err; inn.)
:banlunnirw to the ftrlluninQ
Disision of Kerr Resources,L'ndetRnntnd Injection Coninal Program.
till.\\seer Irirl twit)'" zm,uad vrrfacr: l� eft.) 1636 Mai SerOw Center,Raleigh.K('27699-1636
Itre, Fur Water Sunnh & lithttion Wells.: in aMi(ion to sriK%ng the form to
t.c.()uhrcasin( IcnCahtit'IainNn): unknown Ift.) the addressicsl aboie. also subini( (vie min of this forma Kithin t11 (jays of
eompk:tion of Neil abarrdin into to the,oiwty' health departm¢tl of the comity
unknown w here atminioncd
i.t. Inner casin�tubint ieny�th(if hitunu): (ft.)
6 ,Streen length(il'tat+ii+nl,unknown (ft.)
Fonn Gil°-91r Nanh Caroliin J.Tnnnncnt.it Ens iromiwin aiiA varara!lt:saivacs Un rswn of 1b'ater Raonntis Ro cscd Ai"a:1if i

WELL ABANDONMENT RECORD t,,rtrNer,rttt'koNl.,
This forum call be ukcd lot silvgk of multiple t,rlla
1.Well Contractor Information. WELL ABANDONMENT NT DETAIE S
Scott Hunt, Jr 7a.Number of aeBs being abandoned: 1
Well Cotmacwf!wale tact hell tmiief Ix3usiLtU,ab%lotanz well riu lm,'hei plett:m 1 r<v .rnrlgi t•r�.a< r t';r; lfAJ.}'
CMl�ptt!id.W Ut4AM:f.'.. .,r rr,k itNY YMNNNt.Mr h+rM
4561-A
?b. :lpprutiurta•r rdunrc,rf a Ater rrntaining rn uclh�r: i„al.)
NC,'01Cc,ettrtciarCcrlirw--dianNnatnr
FOR,1 17 ER SI'PP1.,'U VLI S ONI.Y:
SABDACCO
C2+n:pae+Niarrk -c. I r lx of dr.inl"lant U%vd:
2,Well Casstradiun Permit 0:, ,
t-!..r uttl:rl+1,fva`!int:'t>,rvn.,Lr,,.r•.(1.ynJi.SwM.(�,rxax'e Imr4hom elr.r+t 4rw.r�,; -ti, 1,ntrunl lrl di.fnlct'lartt ua•d:
3.Well,use(checktuL4l use):
th Ater Supph Well: 7e.Sealing materials sited(check:all that allph):
❑Ag»cnhutst DhiutacipalTubtic to N CA CcactK Gnat n Rculonin Chit*nr Pew-is
❑(kothemul(Hcming"Coobn Situ It 1 ❑Rmiderriab Water Supply mitWici ❑ Sand Centem Grout ❑ DF%(illy
❑irdusirtapConuncrcial C1R:t;td:tnial Water Supph W-areds ❑Cc»k-rete Grout ❑ Dill Cuttulp
Dirtigatwo ❑ Sm-talq Grout ❑(ira%cl
Ilan-WateT.Supph Well: I:1 Ii:Monttc 51Urtr 17 Cltlltr(e%plan Undet 1g)
i&NIotutonng. ❑krc:atety
Inj"-tion Well: 7f.For each material%elecn'd Alin,r.pritt id, anumnt.,f malrrialc 11%etl:
❑A+tdl tRrcharge QGtuunducarrRrtrtedctltan Neat Cem.:94lbslb ,Wtr:5gal. Sand Cem.:lb ,Wtr:gal.
❑Atlutter Storage and kcco%en ❑Salnut% (lamer
Hentonite.:59s1b ,Wtr:gal. type 2 portlaad Amount:4 gal;
❑Aquiler1w DSlormualcrMums=
❑bxpcnincutal Iochrwlogy ❑Subsickticc Coulnil Prrn'ide a brief dexriprinn of the abancitmtneni procedure:
riGmtherotal iCkosed Loopi C]Tracer
Tremi grout well from bottom to top; no well tag with info
fJGeatWrovi ftati •Ccrolin Rehrm) 00(her(explain uodet 7 l
on well was found
4.Dote wrll(s)ah:tndt,artt. 2-29-24
sa.Well location; MAN 1 8 2024
North White Street Landfill
S.Certiflcatiwr• ln�i:,��.�:tr;, ?r-;.5t:.rzh. ;ISRlE
Faii1H+fiusu�iam 1%.-r:�ilih ln,?t6:rppliC.7blct � � tJ'�il;:,''•�'�^.i
1226 N. White St, Wake Forest, NC 27587 r -' 3/3/2024
PM sisal Add&-%.CT.and Zits ±ic:.v=•se a!'?o:.K4 Well ContraCrtrr cn wen(.buns Dak
Wake lice vgimm- this/:wm, I hrreh)'tertiJt•11ka the wellexi wn< twcrer ah"trtkmrd it?
t':ranh Ravel ill.-tutfwt okin Na.4Pt14) O(Vtorla xr with lis t.VC AC o4Y"0100 or 2(' 0-7)0 if fl/Givi.4"tiffs)Sta"IAx-rIv
cmd lhw u t r,pt'ol this reined bees be c1r provukti to drum%+ell Owner.
Sh.1 arinlrk•and Ittngitutl+in fhtirei•dinimitecwronds ttr dnrimal degrivs!
tit hitAnig v,+alt,cxrx: 9.Site diagram or additional w(di details:
you uta use the back,of this page to promle additictiral%tell sale details IN we'll
Tt W abandunnwitt detaih. YOU rtta%'also altat:11 aMitiulral psigrs ff trccrssan
CUN'�f Rl t'TIUN D1:'I It(lF,\L 1 I is K€I',(: at34\BONED S('iEA11TT.1i.fl-RUCTiONS
.i+::.. uc .y:... .. . .....r.i'. ., .. ..-a`.. ,.i. roue;tic -.... ..r,Y1n•,fufrl wpgdt
ax'i1x ON"WIri"the M vnr t.rrarrec rn.�r aNR V rkn -q"V?-t lv cur:wA n,r cure A.rnc k0a. For All Wrib: Submit this form within 0 dais of completion of uell
6a.Well ID#.MW-1B abartdernuctn to the fallowing
Dtsi'sitin of Natcr Re n Resources.Infosatit►n Processing Unit.
b 28.5 1617 Alai)yen ice Center,Raleigh.NC'2 7699-16 1 7
eb.'i'otal"ell de lift. {it,)
Illb.For Iniection Wells: In:wldilion itt sendirtg the font to the address io ttla
abmv- also submit Otte urp� of tins form%whin (a dots of t;. nPIction of cell
6e.Itftrcltttle dlanxter:2 iis.} a bandunntem to the folltn%tnG
Di%ision ul Rater Rewlurces,Underkruund Injection Control Program.
wl.Water te%•el tx4nvt -around.%urface:.7 (ft.} 1636 Mail Seniec Center,Ralcieh,NC•27fi99-1636
known 1(k. For Waternfect bgmlh h I ',u l'.11 lit addition to--wiWing tlu farm to
tit.Outer calling length,if lato%nJ: unknown (ft 1 lilt addressttsj at+o%e. also submi( .ate top% of this font ttithin Ott dais of
completion of acil abandomtunl to the i:vtumv hcatlh depantncnt Of fire collrQ)
unknown wlt:rr Ationdoncd
hl.caner easin;:;tubiny length(if MnunY: (ft.)
(if,Scrft-u ktiglh lif hgownl:unknown ID.)
Pon"OW-ift NonhC'arohrm Dquiurmtna1 En+rrommitt atd Natural R.somes-an own Of Water lU ooV5. Re%set At"L 54 M3