Avery_Well Abandonment_20240507

WELL ABANDONMENT RECORD �� r memalU�ONLY;
This fohn can be used fir single orJ1110ple.)wIls
1.Well Contractor Information: �/ )YELL ABANDONMENT DrTAIL.0
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Brian Ewing 7a r`lunnber ofHclls Ucinp abandoned:
welt Cormao'r Name(or%%ill awwf r For wirkpe. oyeemor or hew-5m(d ''supph, welds ONLY wuli lix stone
caxurnrcrr ui•mGairch7rl vu�af,3wly CAR mhJ10 r Ije form,
4240-B
NC Wcl1 ConlmgorCaniSGition Nmrber
7b.Apptnsimvte voluine of water remaining in wcll(s): (gal.)
sAEDACco FOR 1VATFR.SUPPLY%1TI LS ONLY:
CampanyNamc lc.Typeotdisinfictant used:
2.WeIICoastruction Permit td: ,
lit ed1 npryl:ivLde urldlarrrdLv(i.c_Caniim-.Saa:k,YuHarxe.li�aNiora,;etcl Pf tunrwu 7d:Amount of disinfectant used:
3.Well use(ehecicwell use):
Water.Supph•Well; 7c.Scaling materialsnsrd(cbccl:all that apply):
❑Agricultural ❑%luni6palil'ublic, CI New Cement Groat M Bwonitc Chips or Pellets
Mjmthcrtmtt(llcatinglCooling Supply) ❑Rcsidemial Water Supply(single) ❑Santl Ccntent Grout ❑Dry CLy
❑hldwstriallComnicicial ❑Residential Water Supply(511arcd) ❑Concrete Grout. ❑Drill Callings
❑Intl lion ❑Spct:ial}y Grout ❑Gravel
Non-Water Supply Well: CI Bentonite Slurry ❑Other(esplainunder 7g)
i 0monitorine 1311moeery
Injection Well: if:For each material selected above,proside antontit af.rilattdalS used:
❑Aquifer Recharge ❑Gnimuivater Rentediation
❑Aquifer Storege aml ReLoven' 17Sulinily Barrier
❑Aquifer Test ❑Slonawater Drainage
Bentonite.:51b ,Wtr:1ga1.
❑tXpetimerilal Tn:hnotot•v ❑Subsidence Coulnrl 7g.Pnn•ide a briel"deseription of the abandunmett procedure:
06cothennal(Closed Loop) ❑Tracer
Backfilled 2" PVC.well w/ hydrated bentonite chips
❑Geathemial(FieittingCoolin Return) ©Otl)cr(ax lain under 71t) .
d.Datcwcll(s).abandoncd, 3/7/24
5a.Well location:
Cranberry 76 Irt�r.;^_•,°�9: Y�i, ^,. ,' SU"
racility1 IVIVt Nuanc rasilily 1Db(irapplicablc) S.Certifleatiott; DVu t 000,
6741 N. US Hwy 19, E. Elk Park, NC 28622 , Brian,
ri a n,_ Ewing 4/30/2024
Pliysical Address,City,aid Zip Si�llnroarCeitilistl Well a outracrar<; r.'Al b,yn,r D,y;
Avery I1te signdng this fa nn, I hereby cernfy­that the irell(s)was pwm)uhandoned in
Cmnuty J�wi cl ldcn ffibc itkm No.(VINj accordance with 15.4 10IC 02C,0100.or 2C.0200 mull CansdrxcHon St6ruk rds
' rniid dlmt a rnptrof!Iris record)gas been protidced lo7lre u•elf ont1zr.
5b.1 atitudc and longitude in dcitrccslminnteslsccnndsbrdecinr;ol degrees:
(lrstcu ro ht,ark 4,tJtonrg is<,rtrcnca} 9.Site diagram or additional well details:
You tray use the bacl:of tltis.page to provide additional well site details or well
N W abandounteid details. You ma}also attach acldi(iorvtl po•oc s if rrecessan'•
GYINSTRi1G.TION DETAILS OF WELL(5)BEING.ABANDONED SLTBhTnTAL iNSTRITMON.5
t(lerla trrU curalructhia accunl(S)ij UL1W1a5L' Feu•rrruhiple injec eua cue rmn•n•aha•-PA,
melk0AILYtr•ithdansvnne wrindwilcutefonm 10a. For All Wcltc Submit this faun within 30 days of completion of urll
Ga.We'll ID96mw-6 abandonment to the folI0Wff g:
Division of Water Rcsourcres,infor•mation-Pruce_ming Unit,
Gb,Total troll depth: 15 (ft,) 1617 Mail Smice tenter,Ralcirli.NC 27699-1617
10b.For Tuleetlon Wills: In addition to sending lire form to the address lu 103
Uc.Bot�holc diameter.2 (in. abort,also submit one copy of this forth seilhiii 30 days of completion of well
abimdonmcru to 111e fallowing:
6d Water level below ground mrfucc (ft.) Division ;olWater Resources Undergmud injection Couttiol Progratu,
163E Mail Senicc Center,Italcigh,NC 27699-1636
6c•Outer casing length(if Imown): (ft) Inc.rnr\Vatcr Stimih•IS iuTection Welts; In addition to sending the faun to
the.addres(es) ab.9ye. also submit bee copy of this font.within 30 days of
completion of well abandonment to the.county health department of[lie county-
Gf.Inner c rxin,f tuhinytdenyKh(if Imoss n): 00
where abandoned,
Gg,Screen length(If hnost n): (ft)
Fomi G%%%10 North Carolina Depamlx:N of Pm•ironnicm and Na_tuml Resanmees-Dh•ision of ly=r Resol s Revised August 2013
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