Wake_Well Abandonment_20240429

WELL ABANDONMENT RECORD \ i of btldriutl U5d ONLY:
This faun can be used forsingle or multiple mils
1.Well CantraciorInformation: WEi:L AHANDONIHENTDFTATL.S;
Chris,Ruffer 7iL YumheroYirdlshcinal►andu Ied�.1
iYc1[Cauicactor.dame(or�tirlto��MNISanulyati�ntaningaell.onlii9tli rtnaticny) For mrclrlple Nvedfar br,rwt:-uw}erI Sim'. "wells ONLY ulrli Meimie
. - - f97tsfITfCtkl'1.471J0)Nl'NIRJeill)Y1N Cf11P BNbNI! tNlIC�T7rNl,
4223A
71r.Aliprnzimxte�wlnine of tratcK I yt%aining in m IdION (guL)
NCWd1ConlradarCcrtltii:atiotiNntrbcr _ l �
SAEDACCO FOR WATER.SUPPLY WELLS ONLY:
CDavanyName 7c.Type o(disinfeciani used:
2.Well Construction Permit
Lilt QR applk Me well1winkv(hat Cwrth;Strta,"t$narrce;l,;Nctirit;,etc}IJfnutrrr Td Amount of disinfectuni'used
3:Wi41 use(eheckn•cll use):.
Miter Supph Vi'e1L•. :_. _ Seating in ter! used Rhee_k'211, of a)tply)?c. µ. -
pAgricniturat pMtinicipaliPttblre M Ncat CcntcntCmwt ❑13cmomtc Chips arPam
Oi"�cothemr7l(Hcmin000lingSupply) pltcsidemiul%Vatcr Supply(.singtc) ❑5and Ceute. Grout 11 M Ctav
❑htdns(ria(Commr ial " ❑itcsidentinl Water Suppl,.(shared) 13,C6nciv1AGrout O DrillCultinpS
❑hti• thou l7 specialty Grout 13 Gravel
NQn-Water Suppl0 Wcll l7 Bentonite Slurry ❑'Cnher(explain under 7g)
Q➢Manitoritre•. ❑Recovery
Injcetion Well: X.For each material selected•aboie;proside amottrit of mateiials used:
❑AquiPC�hdccltarge ❑Grouiedpalerlterucdiiliori Neat•Ce i.:471b ,Wtr:3'ga1. Sand Cem.:lb ,Wtr:gal.
DAquiferStontge wyl Recovery ❑Salinity Barrier
❑Ailuifrr Test �Stornnsuter Dn►i►iage k
13Et3rerinteutal Techrto[oev OSubsideuce Corneal 7g.Provide a hrlef dcscriptian of th e;aliandnnment procc4lure:
❑Geodwri al(Closed Loop) . ❑Tracer
We11 grouted in place
MGeothenitat(HknfioNCoolingReturn) ❑0ther(ex- laiuunder7 )
J.bafcncll{s).abandoncd: 3-23-24
5s� Wcu'Wcatlnn: APR
James Curl Property �,•��• }y ul?iS'
S.Certification-.
Paci]iglUtvncrNamc FarilkyID9(fappli;MC) {.� (�R
21'12 Broad St:. Holly Springs,' 27540 CI.l.ris uffe ! 3/19/2024
Physical Address;City,mid Zip Signaliui.of Certifud l4'ell Confraciar or We11 O ism-r nalc .
Wake. 0657682817" 13y.sigr2hig#his jorn4 I hereby cerflJy that the irell(s)trey(tcere)abandoned in
Coutiiy Parcel]&Wifk;it nu No.(PIN) [lCtvirlatice ivillr 1 -1:l CAC.Yl2C,DIOrJ.or 2C;0.0U lErell:t aristrrtctiou S1durFrlrels
mid Drat a repyofthis record hasbiie provided 1o71re ivell owner.
Sb.I:atiftide and longitude ln.tlrgnecstminutcslscrnnds or•deeinutl dcgrccs
v c
(IrOl E itotd,olk 4�l&ng igsydfic>:r1) 9.Site diagram or additional hell detatls:
You tuap use tree bacl-of'1 bi_ s,page to•provide additional istifl site details or well
)\ W .abaudoiuucrtldetnils..You map also attach idditional pages if necessaw.
CONSTROr 1IilN D£TAII S OF WFL60.)HFING ABA[VllON SUHl11T TTAT.TNSTRiTCTiONS
• .ttfrhdr.nrN rorYrnlclrort nivnl(s)iJ'mratlra4lr. Fur muhiple bJrrtiare"ar rv�n•unrir suf�h•OAF irith .
11*11 rlx svNicrarsrrr rnnx abn rchaxrirru.iva inN arbmll wrr��nrz 10;1.For All Welk Submit ihis fomt,ttiitktin 30 da}S of completion oF,it-ell
60 Weil 1D •tnT-1 -atiandoomcnt to'thc following:
Diy Atin of WaterResuurces.InformationTruces§ing unit,
22 7 1617 Mail Sei-sice Ccntcri Raleigh,NQ 27699-1617
6b,-Total well depih: (ft.)
10b.For-Meetlon Wells: In additiop to sending the forat.to the address ilr-IOa
6c.Borehole diameter:2 (In,) abo%v,also subndt one Dopy of this form Withiii 30 days of completion of well
:dtatulnnrnern ro the tallnning:
6d.Witer lir•cl.bclow jrou id surface: (ft.) Division of Water Resources,"Undeiground hijcct[an Con Ito1,P►dgram.
1636 Mad Scnicc Ccnter,•ItAlcigh,NC 27610 1636
6e.Outer,casing Icripth(if known):. (ff) loc.Fnr witer Sutinri•'&lniecrtnn♦�relts: In addition to sending the form to
the address(es) abode. also submit brie'copy of this firin within 30 days of
completion of nril ahandnitweut to th" wm►iy health deparintmil of Itte county
Gf.Inner euyiniilmbinn•h:ntKh(if lmuWn);12.7 (ft.
tthorcabandaned.-
60'.Screenicugth(if Imown):10 ( )
Fami GW.30 Noith Carotlm Deputmew ofPnvirontnent aW N4uml Rcsou.2es—Ulvision oM.9rcr Resoluces, Revised Auk 2013
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