Wake_Well Abandonment_20240429 (3)

AVELL ABANDONMENT RECORD rat IwaaliJWONLY;
This fdrm can-be used fair single,ormultipte lstM !
1.Weil Contractor information: )}'FLL ABAND()NM1iEiVT DE"tAiLS;
Chris.Ruffer 7a.Numberofndisbeingabandoned: 1
Welrtpntmdyff Now(or%vWuii=p�ao nail)dunididugnellonlii,l rpralx F
»y) _ nirrinplee trfectfori or otmintcr'l srrp�*. wells ONLY with Ilk .iwue
' rvxistrtrcft�'rirboir<Pwraa+raf,,apn can�ri�iUf�rx�aforin;
4223A
NC}Vctl ConiractorQtiIf=I Hot i Nntrbd 7b.Ap'prwdmatdvolwne of hater remaining in itch(,-) {peal.)
SAEDACCO FOR NYATE SUPPLYWi LLS C!N!.Y:
Cati�anpNamc lc.TyNelif disinfeetant used:
2.Well Construction Permit 9.
LtsfullappftivFleuxllpurtniZr(irC.r�ruti;Stufe,l'urturmtL�ertionrlc)tfStmrrn
- 7d:.tiiount of tl3slnfectant uswl:
3.Wrll use(checlr hell we)-
Water.
.= ... _ 7iWl e ink m scd;(cb appiti) -: -
St a1 atcri:iLs d cell ill itiat
❑Agricultnr rh pMtinicipal/Ptlblic ' M Ncat Cement Grobt ! ❑13cmonitc Chips ofPelicts.
t7C�cothcrm:tl(11cmin ;Cooling Supply) 1711csidcroial Water Suppfs'(single) P SMAOinirril Gmut p Dry Clay
❑ItdtistrialfCommcncial ❑Residential Water SuppF-:(stiarcd) ❑Concrete Gmut ❑Drill Lltttings
❑Ili lion 13 Sp�tialty Grout r]Gravel
Rou-AWterSupplrWell. ❑BentotuteSlurt3• ❑•Other(explain under 7g)
ligManborine. 1:31tteoven',
Injection Well: - 7 f.For each�uatcri:d sdectcd aboi.�pnoiidc amount df.til iteHals n9ed:
❑Aquifcritcdtarge. �Gtouirdn�lerRe»tedintion Neat Cem.:471b. ,Wtr:3gal. Sand Cem.:lb ,Wtr:gal.
[]Aquifer 5tomge and Recrn'cty OS:dirutj-Barrier .
❑Aguife'r Tact ❑Slonmvater.Dralniaga
❑Eyaerinterual T&huoloe_v []Subsidence Corrrni 7*Prui ide a brief ilcicription d(ttic alieudnnnimt p -dun:
❑Geolhetinal(Closed Loop) ❑Tracer
Well grouted in place .
®600thennalMC60R¢C001in Return) ❑Other( lainunder7u)
4.Dafc.iicU(s).abandonedt 3-23-24
ia.WIinlocation: �• Z024.
James-Curl Property !riivi ;` !
,�
racilit/QivncrNurmc rani!".Ins tfa Iicablc 8.Ccitiiltcatiov: ,
2112 Broad St: Holly Springs, 27540 UII.rIS RLJIIer i 3/19/2024
Physical Addmss,Chy,and Zip _ sikrghfrgor Ccrtir)w�Vgll C0111mcrar or Wd1 Owwr. Mile
Wake 0657682817_ Ily.v!,gntlq flaslonn;I hereby certify-lhgt the irell(s)tiros(leery)ahundo»erl it, .
(lauutp . " Pared lileriii["icitfrtu No.(PiN) - 'i1cxvn1d1jc:au;illa13.f:voldox,0160,ur,1C.000.MU11-afisneetiunSlartektnls
slid iJrcu g coprofllrrs record 7ras beivtProiiderllo lire well owiaer.
k Laticudc'and longitude In dcgivesrminute0k onds or dcciai;tl'degrecsi
(if«c11 rvkl,an,.,I;ui!nngisslimcl li) 7.Site diagram or atldidoualiiell detalts:
Yon tua}•we.lhi,back•of Wis.page 1n provide additional A%VU site di:tails-or v4c11
N �Y .abandoiuneui deurEls.:Iyou tuoy also aitnch additional poems if necessany_
6)NSTRifCTIOAi DETAILS Oiz WELL'M BRING AHANDONRD SURNWITAT,iiVSTRUCTFQNS
:tlruth n`rU cvrxarmr&ura n•�vrel/sl:1f uvailu k. r6r uultiplr rtrl'rrrirur'w•rba-miler"PAT
arils ONLY irith dw svmw tonsrnrnaic'rzarehima��ar,Tarr cvr:rrbmii wrepnrr 10a.For AllWettc: Submit this form n ittrin 30 days of completion of well
6a.Well I64.MW-6 abIndomncnt to the fullovving: '
DIiisian of WaterResourcm,Information Pramssma Unit,
6b.Total depth: 27 {[],)' 1G17 l%bii Seitiicc C6t-Lki Raleikb,XC 27699-1617
10b.Itor.TnleeAnn Wells: ;I]addition to sending the form to the addiess In Kfa
Ge.Borehole diameter 2 above.also submit one copy of this fornr.uithiu 30 days of completion of well -
(iu')' abundonntem to the following: I„ '
Diviatou of WitterResourres,Undcrsround Injection Cotaroil•Prdgram.
f4L Water lei.d.below 9nmrnd slr rfacc: (fP.) 1636 Mail Service Ccnici,Raleigh,NC 27699-1636
6c,Outer Casing length(iflmori n): (fw) loc.Lnr Writer Sunnh•�Tnfectiou NYelis; In additian'to sending the form to
the,address(es) above. also submit one copy of this form within 30 days of
completion of well ahandnimrent to theiooimty health dcpauntent of the c6unty
6L Innereasinj!tufi; g lurinh(if!mourn); 17
vvhcre atnndontid,
6g,Screen length(if Moii'n):10 (ft.)
i
t
Faun G1V.30- Nonh CamUm Depanarm afE,nt ironmenL and Na umi Rcsou2cs-DIvislan of WarcrRooatrxs PL v'ieed Augusi 3013

. i
NVELL ABANDONMENT RECORD . For h9cmilllsdONLY;
This fo'rtn can be used for single of multiple hells
I,Wcll Contractor information: rWFLL ABANDONMENT DFTAtIJS .
l •
Chris Buffer 7a.Number 6f►tells being abandoned: i
1l'e]CCpuraclor.Nsmc(or�:rttooe�YPcaarlally aliautaldneaLlldnld411�rttropcny) Acu• wg1tiple. rryeaiar iw nary-14ilrer sippb,. walls- "O,YLY. with Me- sane
CUf13fifGtiaJ riihaltlNlRI�Wl1,IY)rt COUP 5711A41Jf'WICfOPN6
4223A ##
I ,
NE Weti(bniiaaorCetllfaltloti Nmi$cr ?b.Aliptneimatc►nlotiue of tt utty rtemaini ig in it'ell(rc}: . (gat.)
FOR WATFR.SUPPLY WFL SONLY.,
SAEDACCO
Caugatty Natnc' ?c.Tyyte'tif disimfictant rifled: - -
2.1tVc11 Constructiau Pcrtn[t d:.--_'---- --_ ---_- ----- -- _ --- -- ,
Iltrtrllupi�dli+eblsuiilperttriLr(La'_Ccurh;St7ta•J'urramith;rrtia:•.n1rt jbuwrt 7d:Amouutof6infecfiintused:
3.Well use(chcdcstcll uscj:
.Water Supply Well::;. -7c Scaling materials asnl'_(dioctc all ttlTt apply,):: _ _ _
gAaritpltiti tt pMnnicipal/Pttblic M Neat Ccnlent Gtout ❑Bctnonitc Chips ofNJI s .
17Cwificrm••tl(HcatinglCooling Bupply) L7ltcsidcntiat Wator.S`tipph(single) ❑:Sanil;Crriw4d Grout 0 Dry Clay
❑wgslrial1ConungqW" ❑Itcsidential%VutcrSnpplyy(slinicd)• ❑.ConetewGrout 13 DrillCuting�
❑Lri lion d Specinity'Grout ❑Gravel
Non-Water Supply 1Ve11: ❑Bentonite Slum' ; ." ❑Other(explain under 7g1
tl9Manitoring. ❑Recovety. "
Injection WCH: 7f.For each material selected above.pirovide amount df.muteHnts tdsed:
❑AquifcrRcchar& ❑GroundnalerRent aknion Neat Cem.c941b. ;Wtr:6gal.; Sand Cem::lb ,Wtr:gal.
❑Aquifer Slotuge aW 12ec- ►vciv .oSalinity Barrier
❑Agnifer Test osibrunvtuerDmiliage
pE.eparintetual Tbclmology l7Stdtsidence Comm'. 711 Provide a brief dcycriptian of the"abandonment prneivlure:
❑Geothermal(Closed Loop) ❑Tracer "
Well grouted in place .
I7Geothennal(H6rjpjWCooling Retum) ❑Other(ea lain colder Lg .
i.BAN well(s).abandoned. 3-23-24 ;^p` - 'l v r. 1, �—
Sa.Well mention: M
T .
James Curl Property tfliJ:ri
1radlitffhvirrNtunc Fxilky Ills(fapolicoblc) $�Ccllific.iU0i1: D'Fv`(i`u�U
2112.Broad St:.Holly Springs, 27540 Ch rI S .Ru 1 1{�er 3/19/2024
Pli}'sical'AddPcs;City,and Zip sigrcyttlm or 0:11irnd Well Colawar or Wcll fjirtur U yc
Wake, 0657682817. BY.signing this farm; I hereby certify;dial the irell(s)was(lama)ahandoned in
{budiy 1"wrel ld.c, kilt bnNo..(PINT ao.wriltnJcc ivith 1J.4 1'L'11C OZC.010O.ur 2,C-,0200 lEell Gvririntcaort Slaridaryls
- _ midlJrirtacop}bftliisiccordJracshein�providecltotliewelltittitcr.
5b.Latitude and longituge In degmusJminuteAcconds or decitual de s:
(ifsiell Eyelet,ore L'ulltiig is atiilTlcicrA) 9.Site diagram or additional well details:
You map-use lire back of tbis.page to;pnipide.additional well.site details or%sell
N' IV abandoiunent details."You may also attach bddjtionat pages if necessary.
CONSTRI MON DETAILS ON WELL(Si UP--INC.AB. INbONED SURNInTAL iNSTRLTCffONS
:tllruh.sirli cr�rslrltcGort r>cvrilB)1J airallrfa+. Fw urLfrifrlr irfrriiori ar ra�nnr�riir
H sL/plt' "
ellsONL'Y�t_tih rlx dumearucsenerfioir'�arrilUrr�lrai 3ua ern nrhtrctl.wrefurm." 10a:'For All-%Vdk Submit this form vvitbin 30 days of mmplction of wall
6a tYcll ID#:Mw—x abtindoumcnt to the following:
Kvishin of Water Resources,Informat:ion•Ppocessing Unit,
6b.Total well depth: 50 (n,} 1617 Abil Service tenter Raleigh,NC 2769971617
10b.FOr-Tnlealon Wells,J11 addition to sending,the fotm.to the address in Ioa
fie,Borehole diameter 2 (tu,) abovti;iLso subadt one copy of this fomi iyithii!30 days of completion of%ell
abitndonntem to the fo11o)ving: I;
Divistou of Wanly Resources;Uudeigraund Lijecilon ConlrahPr6gratu;
lid.Water Ievel.beton nriuitd surface: (ft.) 1636 MAR Service Center,Raleigh,NC 27699-1636
Gc Outer c icing lcnptb(if Imoyvu): i fh.) 10c FnrlVater SU1 ll1x.&into iwi�};�lyv; 1n addition'to"se.nding the form to
the 5ddress(es)abot�e.'also submit otie'copy of this form.within 30 daVs of -
coniptctiad-uf%v�ell abandownent to t[ic counly Health deptirtmetd of the county
j,Kh(if lmuyvn): 17 (tl.)
lvlwTc abandoned,
6f.ItnereasinWtubiaF ttn
6g.Screen length(if hnot►'n);10 (ft.)
Fomi G%V-30 Nonfi Camum Detmuttcnl of Environment cord Niuumi Resources—Dlt'iston of Water Rcsolums� Revised Augur 2013