Edgecombe_Well Abandonment_20240423

WELL ABANDONMENT RECURD ��, ror IMsr>b l u�oNl v: a
This foitn can be used fbi singly or nuilliplewdIs f
I.Well Contractor inratmation: \ WELL ABANnONMENT DFTAILS i
Brian Ewing 7a.Number6fwells being abandoned: l
'Nc]fCoGraeforNauie.(ort«ll�nc pcaaually abamtozzlaZ;acOonhi4tttrpia cry) Fa• Rtulopk .oyecticot .or meminfer [fVLY with Ilk sazze
obtubrrcn��'a+"ebmt<l�anttnszt inncs�urs+htzUrr�zajFirm.
4240-B.
NC}ydlConnadorCermi[;alioiiNmiz6cT 71r.Appnizimatc volume gf-ivata-ntnfaininginitell(s):, (gull
SAEDACCO FOR WA'rRRSUPPI.VN%Tt 1.S ON1.]
Gnmi�mq Name 7c.Type'or disinfectant used:
2.Well Construction Permit 9:,
llsruAnJtj�l'ivbre.ueU}urarit�lie-Cuvnnt Stczi,Yurinzre:h�rcfinu„crcl Pf Gniwq. 7d xfJtiount of tlLilnfi`cfunt used:
3.r,d!aye(OF&weU use):
Water.Supply Well: 7c.Seating materials.ascd'(cbccli all that apply):':
17rtgricnititiat phltinicip il/pttblic Cl Neat Cement Grout to l3crdotlitc Chip-or Pcllcts
n0cothcrrngl(Hcatinv�Cooling Supply) dResidcttial Water Supply(single) ❑Samul CenteW Grout ❑Dry Clay
❑lndiislrialfConinicrriai 17Resideiu inl Water Suppl}•:(shatrdj t1 Ccjnctete Grout ❑Drill CtitOings
dltti lion ❑Specialty Grout I, ,❑Gravel
Non-Water Supply Well: p Bentonite SlurW ❑Other(explain under 7g)
_ G9Monilodne ❑Recover
Injection Wdl 7 F,.,For each tnan mi;(I sdceted aboyc;prosidc aotonnt af.nt;itcsiaLs n'scd:
❑Agmaiferltecharge, OGrbuiuivater.Remeduition Neat Cem.:471b. ,Wtr:3gal. Sand Cem.tlb ,Wtr:gal.
[!Aquifer Storage and Relzvven, ❑Salinity Barrier'
❑Aquifer Test ❑Stonanvater Drainage
OExperiutental T hno[oLy pSadasirlsi><ti Coaafmnl 7 Provide a brier description cif the abandimment proce. urc
❑Geothermal(Closed Loop) [Tracer
TREMIE GROUT FROM THE BOTTOM TO THE SURFACE
®Geothermal(IJ61iW]UC60li Return) 00ther(ex lain under 7 )
�4.DatCwet!(s)•abandiined: 3-28-24 !'
• o �
5a WCB location: .
Former Edgecombe Genco Plant jr:. i. 's'•r, ':::�+r'z ur.:a
FacilityiChsrsrNumc Pacilih•IDs(f:ipmilicable)
8.CcrtlQcatiou: U > �Ov
6358 Battleboro Rd., Battleboro, NC 27809 B r'ca n _E ' 4/3/2024
PlniysicalAddtcss.C[h•,and Zip Si ahzn<ir itirxyfIva-0izuia:tor<_,r--.'.ItOivt* owe
Edgecombe County 1iy si�ntr{s'8tis f6z9t> 1 lret>by certify';rliat the mrell(s)iras 6wre)an arjdoned in .
C4mufty A cel lilariliticitlnu No.(Pill aoacvrr idwe irith ISA C,1C 02d.010 -0r 2e.0200 ffieU Cehnshucrion'Srimckkils
azid rlrnt a capvof t7risrccard hakilem provider!to dire well owner.
5b.I�ttilitiic aril liinr fade in(tcgrceslntimtiteslsccoads or dacitxtal°deRtxesc �
(Ifu•ell]`alit1 ozu;taiilnng is mitrmckli) 9.Site diagwem or add idouat n'cll dctaH
You:uiae.tlie bac}:-of Wis.page[ti'pros rile additional i)�il'site dztails;or hell
1a W. ,abtodotmtentdetails..Youma}'Also:utacltnslditioualpatesifneccssani.
CONSTRITCTION OF.TAIL.S OF WFIlt(S)BEING ABANDONED SUBM"TAi,iNSTRUCTTON&
:lrlrttlt trel!canstrucltan rncvrd(3)Jl`mrcziJmriJe. Fiv muiaplr'illectirui aY rarn•uitilir
urlds ONLY iritfi rlae svnzeracsrneertohJ�M1nrrrlaarih,ent.i�zu ror vrLmli cute ni: 10a.'For All•[Veils: Submit this form within 30 d#.5,of completion of hell
60.well ID£i•T -1 •abdo annment to cite foilomving:
Dicimidn of WaterResqurees,Information-ProcesAng Unit,
Ub.Total.t►'ell depth: 18 ([},)• 1617 Stail S&vicc Cotter;Raleigh,NC 27699-1617
. i
10b.For.T6lec0on Wills: In additioi)to sending the form to the address In-loa
6e.Borehole diameter. (in.} above;nlsa subunit one tog of this form withi i 30 da}•s of completion of%(-ell
abauddunical to the fallwdilig:
-Di%istott of'%Vd1er Resources;Utidcrgrouud Lijectlon CotitrotPrdgratui
fzd.Water level,below,"nd surface. (ft.) 1636 illril Senicc-Ccil' NC 276'J9-1636
6e Outer casing!era h(if loon nj (fw) 10c.Fur\Voter Sunnly.�C iidcrtinri Wells: In addition'to sending the form to
the.addres(es}a6gve.also submit,bue copy of this fom' i within 30 daj•s of
eompletioi-or will abandonment to the county liealth depanme>id of time county
6f.inner casinoulling length(if lmuwn): (tY) sc]aerc ab intioncd'. p
i
6g.Sereen length(tf lmotrn);lo (ft.)
Fama GW-3n Nortli Catulli>,Depamm�m oCl3nslennment msi N:iEuzol Rcsoiuecs-I}Il'isiostoCPia�rRcsourcrs RiNiked Awl 2015