Alamance_Well Abandonment_20240419

s WELL ABANDONMENT RECORD - lQ For fracm I Usc ONLY. '
This fai[[t coo be used fdr single or multipte l4,ells t_j
1.Well Contractor lnformati(ia:' WIFLLABANDONIVIENT-DETATLe `
Chris Ruffer \ 7a itTumberaf�rdlSUeinabandonevill
�WCIfCAaradior.N3nir(or.%v'll owwr persnr�ally AmIntWe nietl on-his71>Crprapc»y) �' uitrtnple ofcrtlar, ,.br .rota-riwferjf sirPpJ)' KefLt 'ONLY csNb !lre .srune
c�,ttsmrigrxuirhmidnnna�it,pin cmrstrhnur'I eP b17n
4223A
71r.Approximatevulunteafvsatu-rti:mainingiuv�ells}x ( d.)
NE 6Vd14amragor�..rtifaitiodNmibcr �',i;
SAEDACCO FOR WATER.SUPPLYNVELES ONLY:
Con+pany Name 7c Type of dhinfectant used:
2.Welt Construction Permit 9: ,
Lkd all opiihivNe well Wrmils(J e.CCotrrgv,Stala,1'arlmrce;brferNuta.el i If trrnwn 7d e41ltOnnt of t115infClts111t'ttSed'
3.Well use(checks ell u.+c):.
Water Supply Well; 7G Stating matcrials.uscd(cltct[c all tliat apply):
tM Ncat fcnicni.Gtout C1 Bcraoaitc Chips or Pcllcr�.
ptsyricultitral ghhinicipal/hIblic p
O(irotlicirmt(Hca(imVCoolino Supply) plicsidentinl%VatcrStipply(single} . 'I7 Said Cement Ghoul .❑Dry Clry
❑hutnstriaUCcnirmcreial 1711csidentiat Wattx Supply(stiatr d) El Concrete Grout ❑Drill Collings
Dlrti [iou O Specialty Grout E3 Gomel
Nou-Water Supply NVcfl: 0 Betdonite Slurry d.Other(explain under 7g).
29Monitodng. ORecotery
In jectign Well: X For each material selctUd"above;pi aside amount of 64(ctiats used:
DAquiferRccl—.or _ OGroundna[erltemcdi5uian Neat Cem.:94lb. ,Wtr:7g'I.;;i." Sand Cem.:lb ,Wtr:gal.
OA"WerStorage atvl Recovery EjUinili,[farrier !'
❑Aguiter Test ❑Slomnva[er D.rdiriage
OExpetimental Techuolog_i�. OSubsidence Corb[ul. G
7„,Pravidc a brief description of the abandonment prrteedurm
t7Gcothennal(Closed Loop) . OTOced. I T '
Pulled 1 temporary well and grout abandoned borehole from
1;Gcothermat(HtntinglCoolinl[Relurn) ®Other( lain under7g)
bottom up.
. 3 15 l
d.Datcwcl1(s).abandoncd. / /24'
.r+a Wc@ location: D
Cintas u
8.CcttlRcatiotr. ;
Facflitffn'nerNums PxilitylDN(Eopplicablc) IThtteTFw^«.iC.�?r^:^;rC�.k',y like
601 Woody Dr, Graham, NC 27253 -Chris Buffer DVOQ"B0G 3/25/2024
PLcsimlAddres.Gly,andZip- SiepmilircorC-:1Med well'(nntb.tnror%V01'Chvm-r Dail:
kiamance ByxiS"jing flus'fortrr;I bemby certify liar the irell(s)was(were)ahandoned n: .
Cnwrty Pored Id2wil`tuitbu No.4PINi acurtdance initk 15A s;CAC 02C,0100.ur 2C.02d0 Well"Co;uhictiun Stemckirrls
and lkat a cop)rofliffs record leusher4r idCd tv Vie hell orsrier. '
$6,I:kitude and tongitudo In dL• roes.lminutevAcconds or decimal degrccsa
01WIl f,etd,one L-10 tg 4 viffiicielA) 9.Site diagr atni or additio oat well details:
you m4 the the bade of this-page to jtrovide.addi66flal ivell site details.or tsell
N W. ,abaudotmtetu d'elak.You runy atso altach additiotial pates if necessaty-
CONSTRUCTION DFTATLS OF%VELt(S)BEING ABANDONED. SURN TTTAT,INSTRIIC H NS
altadf uc1!mastructiurt tvcvrills)if avalfwla. hw multiple ii�rction'or mn•r•atcr wpplp - -
nrllrOVL1'u�di the svu;crarsuvrriaidnl;nrrrhu{rrenc)ort ron n�hmlt rurelu,rJic Na.For All-Wells: Submit this foitn within 30 days.of completion of well
69.Well tD#•Tmw-i
abandonment to the following:
Dii'ision of RratcrResiturct�,Information-Proecrung Unit,
Gfi.Tataltselldeli lh: 24 1617 ALL SvMce Center,Raleigh,KC,27699-1.617
(ff.) �, .. .
10b.Fnrdn leelloa Wells: _In additioti to sending the forn►.to the address in Loa.
Cie.f3orttiole diameter.i (iu.) abate:also submit one cope of this,for it i4ithiu 30 days of"completion of aiell
abandanntenl to the follo}t•ing:
Gd Watcrlescl.bctots vtunclsurtace: (ft;) DivistouofWaterResourees,U6dergrnundbijectim[CouttiolFr6gram,
1636 Mail gcnicc'Ccnfcr,R4Ici-h.NC 27699-1636
Gc.Onter casing length(ff lmown): 19 (fd) tOc.rnr W iter Simnh"1Cr iitiecttnBi Wcllc: In addition to sending the font to .
the addms(es) above. also submit,one copy of this forth within 3D dajs of
comptction•of ivcll abandonment to the county health dep:utmcn[of the cdunq•
Gf.Bmcrcasinwtubing luigth elf known): (ft.)
velure alnndoncd..
i
6v.Screen.lengllt(if lWown):lo (fL)
Flint GN-30 Nanlr Carollm Dcp�rtnxm of Fnti ironmeat u:d N uurr[Rcsou2cs-QIti(sion oC War`r tteso i devised Auguss 2011