Martin_Well Abandonment_20240401

N R:3 rE_r ABANDONMENT L3....ORD (ar tntemat 11.3 04L tY" l �t
t to eiE C tiittractnr lnft4d it4 4tinti . ; WELL ADANDtlltiitlIENJ DETAILS
t'
a.For Geo rtihePD1 or Closed-Loop Geothermni��elis 6a`ving the Mintz
`
z StOzirt.Sprulll , 7 p . _
t'e f i<t>sa,rnetar ri1 talc tar t e)attdt{rts5 ttssiSyltbantlaning r+'e!E qn hitrlMr pry t;riyf well constructton'depth,.Asily 1 GiY I�is neEded Ind4ctrtc TtrrA1 NUMBER i�f '
t Weite,ulindnncd.�tao��---.. 1 u -
219 A
7b...Approximate kolnme of 44 ater reniatning In vFellfs)! a r (flaE S
Vt, t.Clt f t)t}}r cNtrCCC4sfivatib s i ua tx-f; t ;rP ,r
DES-SCaI
FOIL WATER SUPPLY WELLS ONLY;.
HCL
t' rr.Frury Barra 7c.Type of disinfectant used
2 Melt coastt'xction Pcrrn4t d _ _. ppat r�
irni ttrrr r
tae sli tvtivk,rati tt yr rt7 ff a. (JC'f var(.,Sr�re>i,ir rrtm,:e.etc.)tfknvnn U ' IG 4��h to
t t 7d.Amount of disinfectant used.
4.lilli4S2(L'hei l.4tC12 ntit}
at er 5upph.Nvell 7e.Sealing materials vseii,(check all that apply}
I !
BCnYAntts <ilapb or Petlet,t
fleulttil'Ftt 't,r } f r ea 4.d Ytufti4{}M trynlllV� .:, :r '. y y. t rt , V } -
L;Cr<itihs miai t Fieai4n G isrinie i l{,} „S Recidertiai coact r S'Hi ply.(single) t� Sand Cemei4t C,rtiur C}Liry ay"
C.;frsiltf,ttipl'C_'onirn r cjai'.{ Dlle�idcrstial Water Su"pply(shared) S C:oncret Grout +• t7 BrillCutiings '
lrriretnvn i
0Specialty fixrtiut; i ❑Gravel. � ;
Nun-Water Supple i4eT2: Lq Bentonite Scurry Other{exiitain under 7t;)
lc�lcnitcring CRccorcry ;
!n•lc:cttan 1'eil: 7f.for each material selected abovii4rovide amount of materiaal used:
i7Ayuirer•Itecharge Obu.ndtvatcrltemediotion JO (� $ C�rOUtV+lell DF' i
triiiquifer Storage and Rectster, ` i I skilinity Wider
'r?atprmwatcrDrama:e 3 {bS Read}!rllix ConPl`�t8
. uiier rest L.
fl:tperin{entaT Iecitnnkigy j E 1Subsiciante Control
_rtiot�tlidrmal(Cau d Ltroli) '
ce grout'.
u S><sndonment proceure:7n l
UTracer grout and fop3 co ncrete ,
Pumpedb rt®ni
wtieoihctmal(kIcuting'Coniitr }}eEu;n} t-]Other(ex lain under 7g)
2/011202
4.Date i el{(s)ahnudoue€I , F ..
a:Li elt location - H !R a 1 In'fit! t
t;
[�Q Former Cdltralrt Prod
a IRit,f rl ai 7 �r
1 J acr{ity f7xrtct inn e facility ID,1(ifapplicabie} ll G rti[icatrott r. ;
6 0HV�iY,t7_$1ttNamstorn;=NC27832'.
Pit4slaii litdrc>.Ury aisdtrir t Sig{ittareUfCerufi �Cont or I've IV c,• Date .
Gl1Pt i i
�y stgrrin�tJrrs Jornr_ 1 tiered>3 rertrfv that tFte ctetl(s),ttiras-(iserii)ultnirrinr)ttl in,
f`nufst, Parcel Id-zntificativn No,(PIN) accordance 4slth 1,521 lVCAC 02C.0100 or 2C.0200;Tfell,Cun.stt rctr<=i V1hndi r;f1v
' and that a cunt v1 this record ha.
�roilde416 the Wt'.11 ittV•m'r.
h l ititudc anti Ioiiigitttde In degrreslmlou slseconds or decimal degrees: S f
t uetl tickt,nne Iut tang;�snitlstentj E 9.Site diagram or additional well details:
35.7 5347 77 Q74.102 You may use,the,back of this page to provide additional ti.t=ll site detrils or weil
�} allandonment det€fils.;You may also attach additional pages tf recce ry. ',
CONSTRUCTION DVII'rilL'_Ok'Nti'L(c4}BEING ABAiViM)'N ,i} SUB i1TCTAL IIYS 1 RUC f ItiIVS i
' :trtucltnfel?evnsb7ttirvmre�r�rltsr juf�t:JeFJe J't3�nasrltiplelit}eerrarvrnnn ::atePsupyJy 1e11r � ;i r ,`' } •
ON1.y ilftk the sarxt coo;ini<runrr uh rnttnir{gEt:t.rYna.irin suhnrit.one(irrr;;•'
103. For All'beDS Submit this fontt Mthin 30,tla}i Af camplo ton iiC tkclt .
W�tet SUpply, ill. abandanmenttotherollowmg
tta.Well ITT • Y
Division of Water I;esaurces,inforrnatton PrticeSs4n„Cssitt
bb.'1'iatal K°e11 depth {fd} 1617 faSl Ser I Center.I2atelgl4,ltiC 27,1x99 161'
10b.For Injection Wells In addition to sending the Cnrin to the addr ss m ltta
abavt,also suhixtit one copy of this;term within 3 days eff compl i4Ati tit'.v eli
ffe.Borehole'diameter:.f 4{lit•}
abandonment to th€folly virig
Divisioa of Ia cater Restiarees,.Undergroua l lnjecdon Control Progrnm, .
tcd. 4 tier le;°aj htluFt' round.%Ur,al: tit.}' 1y2o gall Seinice C�ntjer,Raleigh,SIC *7699 1b36
(ie.Q)giter casin{,length{af i,nn4vn}� (ft.) 10c.For S3�ater Sut4Uli&Injection Wclis 1n addtpon in smdtng file lu�ti t4:tlic
addtesc{e,}above: Usti vuhnut one copy of this form tivtih(n0 dcjs of completion
Af well atrandanriai z4t 2A.`the-cotill health'department Af-the cotuity where
ubautloned.
6f.Inner casin�ltubiug length(Ef t�jos£ji)c (it.) #
6g.Screen length(if lu own): (fL)
worth Canr!tna I3cp art{rtent nC 1 nvimamental Quality-t)ivision of 16atcr Etccsnlrc� eta isod ->'-2(111:
Folin(M-.z() r
,

WELL
� . 1.'4+���sr1'1 I91',r.L7(f��'.8•rtE'CO AI ttoi{ntrrnntlt� O�t1:
r L i
y4'El_L ABAis)[IC NIMENI T DETAIIIS� ?
t.IN ell Coatriketor Information ;
Stuart Spruill 7a.For Geuprobr/DFT or CioSed t otip GeotheriaalCW,ils,hivuil it v1n 4
well constntetiimidcpth,only I Gw i0 i needed It dtt trit)f C)I AL`1�k1RtIt1 1c i k
ki )i(:'mtractr!r.Now c rr wi ti t ter r'i 4ntiv shut lAtnn�well a t hia;(Frr PiuRrnv,i hells Abandoned one
) r St f
7b.Approximate cnlutpe of.enter retnatning in ne#ifs)
t.1i t nttit i a!r t nda iirF=i r,ntnt3rr {`')i O -
� 1, - - R WATER SUPPLY WELLS f)..N,
C
M c11117i T attie '. + 7C.T;c'pe of dis#ritcehvnt used: it
< _
r
r well C vngtu uctton Permit
i{i..��Y
i,ii1 ut)t-rr 1C t c nr.rtr:L a!tds,t'ir4 h E L'7t t s amty.Slat.,t u!tar!rv.Or- dJknown
�2 1l2 inch tC�UsAf �-�
7d.Atnountof disinfectant used. r
1 s used(check sit that a
tl ter Sri �4e11 A 7e.Sealing material
t z.+<,)'icultut a1';. : , � ' !:l'tumetpai:Ptihi'tc� i=� �t •r,t r t, a Hentvnitt.C laps nt k'eft tti .
t,entherm�t{E!e ttrnztt clu5{)Rultpiy) #tt c!dential�4ater iuypiv(single'} t i Sand Cement Gni3dt ❑Dry Gtati r,
(
±:3lttdustriitl?Contmircia,i r ) r_7Resideiitiut 13'ater-Supply{shared} ISCen Ctorete out ❑Drill Gutungs
tWtCtri r lion i O'Specialty Grout" C I Gravel
r b Qther(e>;ulain undyr 7g) l
Nutt-Water Supple 'i1 eli: L'i iietttanito Scurry t
't lotiitcring ORecovery
likiertion Well- 7C For each material sclectecl above prat#de tiniount of#tixter#als utcd
C`rlilttiter iZccharge C)Gvriundwatcr Remediation 6 tons Glaye Silty Still 4;.,!
Aquit+:r5tompondRcc#n•ery GSalinity Barrier
1600 Ibs ready mix con`rf
C p iluifetTesti
'Exl�erut;eniak Te itnol�tp s 0Subsidrncc Cottirot 7g,.Providt o brief description of t#>eiabandontnent procedure }
[ c;ettt#turri�+i(C.iasedLoop C3Ttz#cer Pjc'�G@C� Cir��111;WeIi an{j C0111P6000: ��iC1C#E't f��i.tC
Getsthi'11A(llc'atirt ,Cooling Rclu0) E;Uther(explain under I }
�jQ
}}
�f2Q24
,., •�i<Dine tveli{s)abanilancd - - - - � -
�2.i'4tlt t�teatittn + ', ,�- - •-• I.� ` _ .
DOT Former Galtrain`.`l'rat
S.Certifict#flan
_
2820HWY17Willlar ©i 7892 2/12104
_
Phv ical Addmc .t A-% and r'ttr } Sianattxr ni Centtie tVet1 ctor or tipll Uwntr Datt
rtlSrttn;, B}':.tigrtiitg tftas,Jtrtr I hereby certt}y'(htu the,ttelltrl }sac{,octet nnctrtrlvrrc•t!rtt
t^i=unti Parcelfdrntifcutetilln(PIM1 aeeur
) darite'sr!!h 15i VC.:9CU?C:W10adr'Ct02�fll edf_ t?ttsdru..Pirr>t SPari'dzPdr ,,
t and beat a cols)-of this re(?onl has heeln prz>.iild, .tv 111 Hr el �xncr,
51),Latitude and longitude in degrcestmknuttsdseconds or decimal degrees: �!
tit,veil field.one Lit ton).is sufficient) ( 4.Site diagram or at#dttioti well details:
� '7 5r�'S1 �� ��4 �� . You li use the'tiack of this putt.to,protiide additional Veit site t I ttfs nraptCl
+l :ubandonment-del ils You rit.'iv al b itttach:}ddrtian�tl put cs tt n ce5s:ry
CC)"VSTRlIC7 i[)!DI<'I ,ILS Ctl 1'i EL1.4 BEIN ABA t.t7l?�I t) StiB tITTA ii STFik-TibNg
t€•,r<t!ttiit<°rrtutr tcPumrey'u t(a tJmrilv�itx,7'r3rmudttyded:l�tiarcw•trntr-»rrt4i•sttttptyxtPds : - 4',.,
r ()1'('}t19?dtdJ!C51?/nEGVtt.SdJirt7iiRrrP tfl[t ltOFt 2t,Vol?v nsttdlntil0neforrn. It)a:'For t�li'WCiis'" Subintt this fvtm.vtthin 30 days•r�f'compiciton vk �Ctl
Tile,' ' abandonmentk+the tollewing
rsa v+tllIX
IDit
i f Thviskan of Water Resources,Information Frncesstng I.nit t
1f,17 ltlail Service iC.euter,Ralelgh,NC 761994i i
ish.'l otai well depth
10b.For lnieettod%Velis: .ln addition`id.scndinb the fofnt to the.sfdn
shelve,also submit'Dire copy of this;;firm'within 30 days of completion Of Well
M1c.Borehole diameter: (in) abandonment'
to`the}allowing
' t ;
Dkvisinn of A'aier Resources,ilnderground Injection Control Progrs#ni,''
lire,Water level belt►~v grnund irrt cC. (It•} 16U C'1si!5enfce Center Raleigh hG;2fiG92-lti3tt ;
10c.For Water Su y&Iniecti(d Wells In addition"tn stincitng t,c tt)rm in the
tre.Onter casing length(if tbn0vvnit ((t} addressees)above;also subttut one;Copy of t3it�form�cilltin 30 days of cturtpl�u�in
+ of well abnniiiniment to the cdunty Iheattii`iiepattntcrit nt t}te county::Lh�r�
abandoned: j
f $
(sf.Inner casingttubing length tit tuuici it): (ft.)
} } ;+ A . ..
tr1t.4creen length(if knoxn): tftJ
t �1 y}
i F(ill°_;a North t arolfna Dcpartmcnt of Environmental 4iialfty Dwt�ton of tVater Resaurc

%'N d;..'�..A. , A A3"i (e,.v._,...�1'i A..c�". Ti" � �' IZE C01�A.� For ti11C[TS'3{t!.^.Vi it.5':
ASINt?�'tjF IT )EZAII5f '
s:Nvell Contractor littorntadtta: t
Stuart Spruill ! 7a.For GeoprobeIDPT or Closed-LI P Geothermal Wetis�i tt°in he s;tine
------— well construction%depth.only 1 GW-3ti is needed. ineiicate TC?TALl�1J tisBC:1 o1
ts,•n t'erntr;)t 4)r lvtutF^for fret!p n'tta.i:n,•,t c},t!!r at-miltnmE..i%c!i en his'Wf pr(V!ny)
wells abandoned:_
2193-A
_ — 7b.Approximate volume of hater remaining
training in welifs):-,___,�_:.(?'ai;)
.. •- :v? lei fm{{C�c)nlrfli;h)t t:?�rtr?icaiitr,r�e,r;,'~s?—'
GI FOR WATER SUPPLE WELLS ONLY
HCL
7c.Type of disinfectant used: _ -
i�1�A � - • '
3�cls f t)ncirttcttUtt P rtattt _____._ __ �` 1 c (,��+
r ,,1)sP)lt• x t t'nr;c{tae s ,•�t.. t,Pb' tr r t'.S:rmtc•,biurr,rec.CtY l iI%(rmen,xm V 1/2 inch tt�LlvT
7d.Amount of disinfectant used:
' t
3.Well use(check well use):
{
Water Supply\tictt ',e.Sealing materials used(check all fhafctppiy)
I'C;iAgr•irultural 1 CJtvlunicipalif'ublic 0 Nmt Cc t itt Gniut ❑Bcntcmtir t baps or Pellets
Cpcothcripid(({eatin$`t"triitlt�Suj{!}. _ lkeddentias Water Supply{single} G Sand Cement Grout 0 ih}Ctay
f-Ind ustrial.'Ctimmerciai t CmResidt ntial 1Spatcr Supply€shard) C C:oacrete Grout": C3 Ur€il CutiinCt3
r Specialty Grout .13 Grata _
'Itrr+cation 0
;'rten-ti1'uter.Suppiv 6i'etl: _ M Bentonitc Siam _ .. ()thor(r.x{ituiis under 7l*}
�ipfonitasing 0RccoVcty
fnjectipn�Yetlr = -- 7f.For each material selected above;provide amount aC eneterials used! .
t: ClAyn€ferRecharge [7GroundwaterRemediation 50 gals berl$bnite groutvi.
F Aquifer Storage and Recovery 0salinity Barrio 2 ;t3S GOPICI'e£
.-JAgnifer Test [JStonnwatcr Drainage P
i
zt sl)erintt ntai Technology ❑Subsidence Contivi 7g.provide a brief description of tbelahandentisent prtieedetre,
t epihcnnal(Closed Loop' Ll7 rat cr Pumped groutwell DF to aft fromIs.,Concrete.to
�,:.t;cutherrneI( Cc4t titiu i?tiuinl L1O'l)c[(t x lain under g)
Nuating
2/0112024
4.Date well(s)abandoned:
52.Well locafion: [
Right of Way H penned}t • Ali; ;:Al1 a
_ f� 4 u
l ueility'03vn r !ac ity ID#�ncis l.if applic,tblc) 8.Certification:
tti r3�v`�r j
• .' 1440 David-Rogerson Rd williamston, NC 2789 �' 21 l:?12g24
_
PhysicalAdchc3s.City,andlip SignatunofC:eRifine 1vr tractor or Well Own
_[)aft
Marken By signrtrt titmti frrstr t berth} ccrlrJii that the'tivil(rf ;ws(wer t ;ibmidone l �t
r Fatx et tdtntificati�)i No.(PIN) accarPrtnr is ith,JS 4 ri'C 1C 0aC U1-do or 2C•.0200 i3rc 7t C nraNr mcFi tt 5trrrue;rc3.
!Y. Ct,iiritp
s curd that a top}of tests rrcrJrrt hvs hi.jn proWded to the+cell ots7:rr
rxti.'L t+iltude and longitude fit de retslntiuutesise+eonds or decimal degrees:
tt w.l!'tioid,dire lat'lanst is'¢utlit,er+tt; , 9 Site diagram or`addttaonui vvellde`tails ;
€ You may usethc back oFthis page tv proved ittddttional ucll Site cl�tAils or,well
35.775628, 77.C165466 y. .
i'! �ti _ stbatidonment details. :'ou may also aft�acb dditibn ti pre en tf neccssarr.
C'i)i5`f't2iJC710i\DET Al l S OF`WEI,L S BFi tiC:ABA .D_)E� Sushi[1 i AL PricTRt'C i[Ot�S
. 9rt,u.lift'r'?Pc'rMStrmF.,sPapriL'U>k`(YJt 6m,tmtlU�tB. lvrntettttrPei)tjewYPaiornufl-u'atersupplywells
rt;Y�f')x;li.resum[ctr)rsartm t/Lri•t.P.cm.isl)tttipE't=J.�on'cimNtubo1[,onefirRt IO1. For Atl Wells: Submi!this form within d days of ionipiet[in of tyeit
Water supply abandonment to the fallowing
ha.Well 104.�
Divfslon-of Water Resources,inftirmation Prnees5ing Unit,-.
t 16i7 Mal Service Center,Raielgb,NC 27G9916t'.
()b. Total well depth: 3 � RJR.}
lob.For Inieetion 1'ells ,In ad tian to sending the form to the`nddreae in(17 t'
in,, above,also.submit one copy o t$is facto witlttn 3t)tiay of comp'�tion a€well
(i'c.Borehole diameter: ( 1 abandontnont to th toflgvving j,
i x
Division of t'ratitrResources,Underground lnjet flan Cnntrtti 3'rogt aiq
Gd,t1'tifer level hettiiv ground surfiice _{ft:} 1G3f tY A 5erv'1ce*venter,Ratelgh �iC*7b99 163t�
- k
1Qr.For Water Sttnn3c&:init:ction Wells:.lit addcuon to
=ends> sn�fo�mtt)t}te
'ere.ijuter.casing lesigth(if knuwn)f_ (ft.) addresses)above,also submit one;cdpy of this form vv}diili 3ti dn:s,€ rrrtl.(etiust
of well abandonment,to the cotiniy health &fi(i imeni of the rtsttnt} Where
3 abandotied.
(rt.Inner easing tubing length(if wit)evn t
og.`5creen length(lfknnvvri) (ft.)
s ticrilryC.arolina!:)cpa in<.nt of Environmental Quality E),vistnn of water Resources l?•'o!6
t'^[fir litk.it) - ,. _ ,