Wake_Well Abandonment_20240429 (2)

NVELL ABANDONMENT RECOAD.
Far lalcmti idsc l7NLY: .
This.foitn pit be used thf single oe mWfipte hAls
1.Welt Contractor intortnatitn:" ♦%IVLL ABANDONMENT Dr%TAlt-S j
Chris'Ruffer 7a vwnberoftvt lsbcinpnlrandual 1
llrclt'CodrretorNnme(orltnitort'r�jkaanall}alranlonirio s�cll 5niaatltirprapcny) w rrruRiph utrectfav or r na-iinfar surph•. aefis ONLY wlrh Ne sw»e
corlxfnrcG�ui+ezbnirrhxaur�aaf,trip cn�snfwt/f orieforur;
4223A ;
NC Well Cbnlmgor.Corllfi�tUoii Ninifidl
7h.Approximate wilutne of water remaining in ivell(a}: (gnl)
SAEDACCO FOR WATER SUPPLY WELLS ONI,Y: .
Cari>runyNartrc 7e.TypenCdi,infi'etantrired: � �-
2.Well Consttvction Permit
LLs[r±R,uflf>itivblr uwfl}nrrm:Zr�i.e!Cwgv,Stall.Aarj,Lux,Ilyrrlirm,,Lftw)ffllmrwrj. .7d.A tioual of disinfeciiint us&41: -
3.Well use(checicwell use):
°.' .. W:ter.Sapply Wrlic ing rrta sed(til api!lV:
_Te:Seal fcriaLsu icclaa114bat
prlgricnitttiat phtiinicip tItRihlic Ct Ncaf Ccmcmf Groui - p 13enlonitc Chips of Pclicts•
OGrnthermat(IlcatinglC.00litig Supply) ❑itcsidential%Vatcr Supply(single) ❑Sandfiettttnt Grout El.Dn CLty .
❑ 4651rial/Commcrcial ❑Rcsidenti:'tl Water Supply(4ia6d) ❑Con4elc Grout ❑Dtill;Cyiuinl s
❑6ri •tion 11 Speeial(v Grout 13 Gtmvel
Non-Water SupplyWotl: d Hentotd[eSlurry 13 Other(esp lain under 7g)
�Moitilorute_, ❑Rccovetc.
Tnjcctiod`1Ycfl: 7f.For each material selected'above,proside amount of.titaterials rived:
❑Agtdferltec[tarQe E]Grotiiidp tler.ltentedutdan Neat Cem.:471b ,Wtr:3g.a1.. Sand Cem.:lb ,Wtr:gal.
❑Agt[ifer.Smmgc dtni Recovery ❑Saihiitg Datdcr
❑Agnifer Test ❑Strimn}uter llmhiage
❑EVeaintentalTechnology- EiSubsidenit!Coniml I
7(~Provides brief d6criptian of thtaliandnnmcat pmipdun: -
MCwthennal(Closed Loop) ❑Tracer . . -
Well grouted in place
®Geothennal(Heating)Coolin Retum) C30dier(ex laillunder7tt) .
4.Datenell(s)ahandoned: 3-23-24 5:•-
ia.Well location: APR 2 024
James Curl Property L
racilit)X4vncrMone r ility IDs(fapplicabic) S.CcrtiRration: 'N", t1i�i
' n U'rc�F:��l�� '
2112 Broad St: Holly Springs',' 27540 'Ch-ris -Ruffer 3/19/2024
Pit}'sical''Addre$,City;dud Zip Sigmloreof Ccnirwd M11 Cojowlar or W01'4:hernr U uc
Wake 0657682817. Blr• 2Mg Mis form; I hereby certify dray'the n•ell(g tar t s(.wre)ahrnrdoned it,
0 ba �.
Couoiy A114al ldwifriathia'No•(PINj ' amwilance with I M wCIC 02C.0100,ur 2C.0 00 117ell Gtrn is idion Stare& xls
midllridacopjr bftJrisierardlasbe[�[proiidetllo_llrerielfotMer.
Sh.I ntih[de and longitude in degreestminntes/seconds ordceinl:d del recsr
(1r..,'eu ra41,otw 4�tltpng i*a tific)eri) 9.Site diagram or addlaonatncli don,11s:
You tua}use tale bacl:bf this.poge to'ptOvide addilional,ivell site details or tsell
- N W. ' .abattdoiuneru di:ta[Is. Iyou ma}nlsfl alWzit 5dtlitiotml pagzs if itecc�sa[ti�_
CONSTRIK-MON DETAILS OF WELLS)BRING ABANDONED• SURNWITAL iNSTRUCTiONS 1 '
Affadr Veil comirneliarr mwrdls)if'O.Wfarile_ A.i rulnplo irljecdan'to rainnrnrir mj_ 01p
n,elkQNLY nith dw svinerwcsanctlom`izhtirrrh�irraeru.wo rnn nrbmi!rurefyrrrz 10;t:Far eUl Wcltc: $uhtnit t1iEs fans.iiithit►3U days of-completion of ttrll
6a,Welt IDg:MW-2R abandonment to the following;
Dipi516n of WaterResirureu,Info[mation-Prucessing Unit,
22 IGi?Mail Service Center,Raleigh,NC 27699-1617
6b.Tatalivell depth: M.)
10b.t:or Tnlecliott Weds: hr addition,io s tiding tl►e forni t6 the'addi-esi Li'IOa
Gc.Borehole diameter:2 (in.) above,also submit otic top} of this fonit.mithiii 30 days of Completion of well
abandotnncnt to[lie fallowing-
Division of Water Rooutres,Undcrgrrwnd Injection Control Pr6gram,
Gd.Water level.below ground surface: (ft.) ifi3G 114ai1 Scnicc Ccntci,Raleigh,hC 27G99-1G36 '
I'
Ga"Outer ca5in (ft) 10c.'Far Water Simnh•'A.iniecttnti 1Velis: In addition to.sending the form to
h length(if hntt`vo): the iddfe5s(eS)21)OVe.also submit one copy of-this form within 30 dajs of
comptetiod:of well abandainnent to ihelcon Iy health depunntcrtt of the county .
6f.Inner easini ftnliing tcngth(if lmnivn)i 12 (tr) NO=almndoncd.
ft Screen length(if knonp):10 A)
Farm G0430 Nolthearoum Mpartioern ofliwftomwnt aryl N:nraal Rcsou-ces—61i•isian of WntcrRtsolkMes Revised Au o 20 B
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WELL ABANDONMENT RECORD For ltdarnalUs�ONLY; ;
This faun can be u.s for single or multiple ivells
1,1Vcp Contractor information: WFLL ABANDONNIFNT DETAI[S! .
Chris Ruffer 7a.Number Umilisbeingabandunl d: l
WgItCodmcforrame(or ttrllottnffpcmnallyatnminnlnoacll.onhidwvrap.rry) Fay t4OPple_ frJectiar. or rn1mitifarl airvX• wills'- "ONLY will) fLv-%-Swic
. � c�,rirfrrrcfiiur'm6o1c.•htiordcRtf.,rrlocmtsnhiUftwitrfann;
4223A
NC ttrcll CanlnctorCcili7i tiioti Nnrnber . ' 7h.Approximate.vadume of watw remaining in gell(s):" •• (ptt!)
SAEDACCO FOR WATERSUPPLYWFUS ORIN.
CompanyNamc
7c,T�gtciif,disinfeLtant used: 1
2.Well Canstructiah Permit 9:r
li4rrllupl>t1itrb4•uellpermlLs{is!Cue�rth:Su:le,l'uriruale.lnjrcti�r;.ric}Iffitmwn 7d.Amountofdisinfecttint'used: .
3.Wdt use(dicdcq•ell uac):
7c Seaiio matcrlyds usc(1(cticd.all that a .
Water Supph Wc1h_: PP l._)'
pAgrituititral gRltinicipaUPttblic M Ncat Ccment Grout- i 17 Hcmonitc Chips or Pellets
RGcothcrm d(IicatinglCooling Supply) pltcsidctrtial Water Slrppb-(single) '17 Sand:Centent Grout 17 Dry Cory
❑baltisfriallComntercial ❑ltcsidentL•tl%Vatcr Supply;(shatod). ❑Concreld'Grout. d Drill Cuttings
❑Uri lion O Speeialt}Grout ❑Gravel
lion-Water Supply We". ❑Bentotdte Slum, ❑Other(explain under 7g)-
29MmiItorine. ❑Recovery
fnjcrtion Well: 7f.For each material selecteal'abo4e,'proride amount.4..marshals used:
❑Aquiferltedtarge OGtvuinits arrltrmedivtion Neat Cem.:471b ,Wtr:3gal. Sand Cem.i1b',Wtr:gal.
bA'quifer Stontga and Recover .OS:dinity Darriur
❑MuiRr Test ❑Stonm%aterDnrlriagc
❑ENperintental Technology Mabsidence Cowin. l 7R proyids a brief description of the abaridnnrricnt prneCdnm:
❑Geothermal(Closest Loop) . 07fracer - - ; -
Well grouted in place .
❑Geothermal(HunGng,'Cooiipg Return) ❑Other( laic under 70 .
d.D4cttc11(s).abmdoncd: 3-23-24 K..r 6-,r". S 5,a tj.
ia.Nc0loeation: -
' ' APR 2 9 224'-
James.Curl Property
PaelilyiQtsner Nmrrc facili v IDtt Of pplicabicl 8:Ceriffl6tion:
2112.Broad St. Holly Springs, 27540 .. Ch.riS Ru11& i 3/19/2024
Phj•sical:4ddtcss,City,wid Zip Sigrj,4u.orCerpned�4'ell Cojaia mwr or%Vvll"0ivwr Dale
Wake 0657682817 (ly•si"Ing this J6rm;.1 ire oy certify-that lire irell(o were(ircw)ahmidoned in
Canaiy Parcel ld_,s tifks tbu No.(PIN) oczurdanve with 15.4 AUACO2C:.010q.tir 2C:0200 ff'c11:Garislntcttun Strinrki�ds
acid lfh t acrpjroftlrls record has beenPrssvided•to tlret-ell oiv ler.i
Sb.Latihtdcantl longitude in degrees/minx[tc:alscrnndsoedccimal'cicgrecsi "
(irtcelt rscld,otr L9tA ijug'is saff iciorl) 9.:Site diagram or additional n'ell dcta[is:
You"to y use the back of tbis:page to.proyids:-additional waU site details or well
)\ W. ,Edoiwnerti details..I'ou sue}also airacEt additional pagzs if necessaty_
CONSTRUCTION.DETAILS OP WELL(S)BEING AIRANhONED S1iRNM+Af.ilVSTRLiCTiONS
:Iffrtcle uc11 evrietrac7iart ntvrd(s)!f uvnllrLriPi. r r r whiple tirfriYiure'cv rtun•nulir xu pp(r
>„�Ils ONLY ri.ulr lire svmccalrstrttcnnidQhoiridogi:icrtr.:wo cna�iLrrift wre frtrrir. 10a:'Par All WelLc: Submit=this forth ni[1dn 30 d;tj5 of•eomplction of tirll
6a We11ID :tff"'-7 .abondoumcnttothrfollowinG:
Division of Water Resources;Information Proceviing Unit,
26 1G1.7 5bil Scivice Cctitcr,Raleigh,XC 276994617
6b.Total,well depth: (ft:) !
10b.f:or,lh[Otlon Wdls:'In addition to seodinrg thzfornr.0 the address iu IDa "
6c.Borehole diameter.2 (iu.) above;also subunit one copy of this fohu mithiii 30•days of completion of ii,ell
ubindonrrtent lu tine f1111m inS_
f
6d.Water lcycl below ground surface:. (ft.) Divislou of Wmier Resourc6,IIndertrnund hijection Conitnl'Pftram,
163E)►tail Scnicc`Cegtcr,Rlcigb,t\(;27Ci4J-Ifi36
Gc Outer easing length(if lmsrtvn):. (ft) 10c.'fnr•Water Sunnly'A inicctlau Wells: In addition to sending tine fort to
the above. also submit.one copy of this faint iv thin 34 days of th
comptetion-of Ave l aba»doimicnt to thelcptmty health depannterd of the c46nW,
6f.Inner '
vyhc abandohcd..16 u
ft Screen Icugth(if Mown);10 A)
Fort G1V=30. North Carotim Dcpin=nt of Ent•iroomenf and Nstuml Acsowres-blyision of MaL-ritesown:s i Rn,iFd Aygug 20[3
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