Wake_Well Abandonment_20240318 (4)

%YELL ABANDONMENT RECORD FoTlnurrwllSQONLY
This 1'00151 Can bi+used for Sinek of multiple%wits
1.Well Contraewr Ifii►raation: W E LL A BAN DON NI E NT DETAILS
Scott Hunt, Jr 7a.Number of nrlls being abandoned: 1
Wdl C7,1u:wtut?wait I"I"all'm tar ltTwllall, fief ptotkm 1 r<v mufrefq, n;e.t,,..r .0 vn014i wells O,YLV wrh the• .-ww
cYM1�7Nt ry,W ir1.,aHrlf,Jrltwytf.+rrM('df wdVion")w firm
4561-A
NC A-01 CntarlclorCertif►calion Nunficr 7b.Appr►xfmate Ilolutrtr of crater remaining in wellls): l^al.l
SASDACCO FOR WATERSUPPLIk'WELI S ONLY:
covvan±Nast ?c.T,%l,e of dWallictant used:
L Well Commuctiaa Permit 0:
1.!:.r.41:4W&94er,.e We wf&o.e.r.'vah.NkNe.1 ferrrtrx'e 11gpUrxt eh.f if Are wo 7d.ukmat of disirrlettaM used:
J. \101 uk(ClIVLk"ell u%e/:
\.rtt'r�opph \\t•II: 7e,.Scalin,•inatrtial.me-d(theel:all that apply):
❑Agrecukuntl D%lumclpol Pub1►t m Ne-il C enk-nt Gnwt f l Rcnlonitc Clips or Pellets
O(inithernul(Iic:uing+Cooling S iltpht ❑Rcci&-iduil A'alef Supph Isirr:lc) ❑ Sand Cemcni Grout ❑ Dn('Lis
❑idusinal-Coomxrcial ORes-II&tru it\\'Ater S4rpp4 mhared) ❑CMICTC1r(imut ❑ [hill Ctdtlnp
Oltti`•allun ❑Specialt) Grout ❑Grj%cl
Non-\\ater Sultllh Well: Ca Ilellktfllle Slurrt_ 1'l Ckbet lexplaut umlet"g►
31Nlolulonnu ❑Rccusrn
Injn-tionWell- 'f.For each itwwriA w Ickt,•d.Alm I--pro%ide attlntlnt of materiak wwd:
❑Atµ ikr kccharge ❑Groundumcr Rculeduvic"I Neat Cem.:94lbslb ,Wtr:5gal. Sand Cem.:lb ,Wtr:gal.
❑Atjulller Storage aid Rgcovcn ❑Salllut% Harrier --
❑AtptitetTesl OStrrmstatcr[h:urwge Bentonite.:5\lb ,Wtr:gal. type 2 portland Amount_2 gall
❑E\pettenental I ochnolog) ❑Snbsrdence Control Prffi ide a brief description of the abandonment pr►cedurr:
00mil►erotal 1Ciosed tmp) 'Aracer
Tremie grout well from bottom to top; no well tag with info
CJGeothernwl(Ntatin �Coolin Return) t 1t3tltvr tot in uludcr^ ) -------------
on well was found
4.Date w c1110 Abandoned. 2-28-24
Sa.Well location:
North White Street Landfill
Fx11N+(h�.•.r`.,•:I, 1`..,I+n lf}-'rfi:fppliCablC� R.Certification: 4rliti::irr;•;7 ;�.--..., :
r� �iTr'Cu3JG 3/3/2024
1226 N. White St, Wake Forest, NC 27587 i, _e�..��_
Put.sisal Addrm.Cih.slid Zip .r tTr a!'S es;l'tid Well ContMYeft nr WCH 01+RT Mare
Wake lit-.tgning this fiwm. 1 herellY remits then dw welffm was twerer eaNtwkrnrd Jet
(Sf,mn !'.aeel1,kndil<•:akfa Nu e11I1,1 eft conleaxe it ilk fS.I VC.-It•t)?r'.alftrl"Ar^t' f0k)1Pti1 C'txt.gnrtAwt:�frxutG>nft
o"J drat o calm of this re(fwd lln+h�ex part rrisrl err Aw w•r11 owner.
Sb. I arinrrle and htngitude in dtymt timinurr�'crcnudli ardecimpl degttrz:
-.1J r+cl:1'x ld.c:ft 1:0 tang n+alJtcaxlx: 9.Site diagram or additional eCll d"afly:
You ota+ tut•dw back of this page to prom ide addimsilal"ell site tktads or►►ell
N W' abattdotunent details. You nta, alga attach aJdiounal pctgxs►f occeman
CONS'TRIICHON DETAILS OF WELIAS)BEIN(;ABANDONED SUBMITTAL MSTRUCT1ONS
.ifhx is ff ei:aprs'L'aclpnr rue,rr<t'.r r7 ve wlaehle t.fr.orrf ify.�r uyre L•.r.:.x,r,n-Mtrttr at.pfi
a,rikONLY wide the mmwk-meNerwri—T ahakkwmrnr.taw car:%whw o evrr&;e ff• 1pa. For All Wrll.: Subinu thLs form ttilfun 30 days of completion of ecll
(,a,%cil Illa-Kw-3RS ahartiolmem In the foUouIng
Dirimon of\\ater Rt.ourcm.Information Processing Unit,
eb, f fltnl+sell do
tlth: 5 1617 Mai Scn 14. icr['cotcr,Raleigh..NC'2 7699-16 1 7
Ifl.l
I11b. Fur lwifetlios Wdb,: In:rtkliliou to sendnlg the furnt to the;r:hlress in lt)a
abo%c, aIw subutit urk cx_p� of this funo uithm 1!dms of cunpirlion of"ell
bc.Ihfrel►l►lydiantrtrr:2 [fn./ abandolli relu Iu the tollonllg
DWIllon of Water Resmrrceal,Underground Injection Control Prottram.
out Water In-el hchfn �ruuafl.urt tc r: 3 (ft.) 1636 Mad Smim Center,Raleigh.NC I769e1-16M
Inc,For\'ldtltr Sumli dF lakctiott \e1 : lot addition to settling tux form to
oc.(}utcrcasinglrn,ah+•iflronnl: unknown fft.! the wWre'ssits) akne. also SubmO ♦4ie caps of this femf ltithin ill daNs of
completion of tseil abartdaruncnt to the couni health dcpartmetn of the counh
unknown whefe ahnndoned
Apt.lunercaring;Yuhitl>;k-tlgth{it'Atirowo): lft.l
bg.Scmn lermth lif Lawn nl:unknown (fl.l
Fonn GWI-itf Noah A'arohetis Deparuncut it Ern aonawnt and Nattml R,:sowes-Dn tswn of Water Rewitfoa& Ro tscel•\1kytrtt tut;