Durham_Well Abandonment_20240617

WELL ABANDONMENT RECORD Farinlcrnnt.scONIY
This form can be used for single or multiple yells
1,We*Contractor tnfarnration: WELL ABANDC►NMENT DETAILS
Scott Hunt, Jr 7s,Number of walls being(abandoned: 1
Well Connacim Naar tot Nell e%nY personals:Ibardanuig%ell an hledrer property I t'rr nvulnpte rA eEistur uX m a-oswer ,I(;'ra) •rN, (I t t I „rh Nee• utvty
r'n1l+frllr rJ41;rho**vto enr I tYm,Nh.."t r#I, A-
4561
NC Woll Camradar Ccn ificalion Nnil#Ict
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SAEDACCO FOR W L rVR S('PPIA FI l.'•(0,1 1:
(90vin'N'rm It Type of disin(ectant uwIl
2.Well Construction Prltrutlt N ,
L.v ul1 upplkvAlr lerfJ prrnriAr n.r.('wwt'..5'wtr,{�iriaeacr.liglrtfxur.etc.!rlkiaurrr
7&Atttount III disinfcctAnt u.cd
3.Will ux(check well use):
Water Supp1} well: 7e.Sealing materials.used(cheep all that apply):
❑Agricultural ❑Ilfnmicipal"Public ® NcatCcmcntGrout ❑ ScrtonitcChipsorPellets
❑Cicothcrm:d IHcanng.,Vooling SrrMIN l ❑Residential Water Supph isingic! ❑ Sand Cenicrt Grout ❑ Dn C'L•%
01ndustrul:Connucrcial ❑Residential Water Supph Isharedl ❑ Concrete Grout ❑ Drill Cuttings
❑Irti •lion ❑ Specialh Grout ❑ Gra%el
Non-Water Supph Well: U Bentonite Slum I 1 Other 4explain under 7g)
EN101111onne ❑Recotrn
Injection Well: N For each mwerial w4ected alcove.provide amount of materials used:
❑AgwferRecharge ❑Grou»d%zuerReuiediatnon Neat Cem. :94lbslb ,Wtr:5gal. Sand Cem.:lb ,Wtr:cjal.
❑Aquifer Storage and Recot en ❑SaIllln(N Hamer
❑Aquifer Test ❑Stonrm ater Drainage
❑Experimental Technolog\ ❑Subsidence C'ownd 7g.Provide a brief description of the abandommemt pnittillom
OCieothenual 40bsed Loop! OTracer
removed pipe and trimmy grout from bottom to top after that
OGeothemal(Heilul�¢+Conlin Return) OOliner 1 sin under 7 !
water sample was gat:herfd •l Z i f
4.Date wrlhsl abandoned: 5-3-24
u lu 1 4 ?n?,t
ice.Well lircation:
H&S Cleaners 11ia`81:•ltr"Talurn-low"'s. on
Facllm(>,1noNiow Facility lIN!(ifapplicklco 8.,Cert/ifiiccation; DVOC>"
105 W. Hwy 54 Durham, NC 27713 5/11/2024
PM'sical Address.Cio.and Zip „mare o!'.-ar.�t d Wetl Cmulactnr or We"Owner Dtae
Durham liy'.rignrr{Y then Jhrni. !hereby certify that the well(s) was fweret ahapkAmed in
Co1wN PA.cl 1&1111tw:aaln No.(PINn rircarthmce with 15A AV AC OX 0100 or 2C 02W Well Cririrrrurhon StcmtJ4irdr
imd that a copy of this record has beevi provided to the well owner.
51).Latitude and longitude in dt•gr•ecsrminutev-A-vinds ar decimal dcgmcs:
Id h ell fcW one Ln kIty m%ulrlcxiv I 9.Site diagram or additional well details:
You Ulan tee the back of this page to prim ide additional well site details or well
N W' abandonnleru details. You am also attach additional pages if necessan.
CONSTRIK-FION DETAILS OF WCLUS)BEING ABANDONED SUBMITT.AL.INSTRUCTIONS
.!ltrxh well LY12YlrvrlttVr fi'(YVaJ'SI:I JI WIJ(IIC. i'er mLJOplr(Ilfe(nIM!X/YIOMtir(d SY�Ih'
Imelk ONLIr Muth rho.moor cwornk rkm IAhdmk,-Nm"Ie-I,v can.mh ml ewe form 10A. For All W'c% Submit this form within 30 duns of completion of well
6a.W'rll I Dig:Tom-9
abatxlonnicm In the following
Division of Water Resource,Information Prucrsning Unit,
611.'f/lt Al NIII dl`(If h: �{},)
20 1617 Mail Service Center,Raleigh.h('27699-1617
lob.For[ruction Wells: In addition to sending the form to the address in lua
abate. also submit oac nrpy of this form within 10 days of completion of%tell
6e.tilircMilr diameter:2 pe.) abandonment to the following
DhWon of Water Ittsources,Underground Injection Contnil Pro%ram.
6d W'atcr Iced henna glvlund wrfacc: 7.5 Ift) 1630 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Suooh & Injection Wells: In addition to sending the form to
6e.Outer casinglcngth4iflnownr (h•! the address(es) abo%e. also submit one cope of this form within 10 daN's of
completion of%%ell abandonment to the count health de}wrtmett of the coutm
inhere itr:indnticd
6f.Inner casin�'hlbin,ten'Kh Lit I:mlNlii: 5 ltlt.l
6g.Scrren Length III tarot n I:15
f''If t Ak-:I I North Carolina Depanmcat of Em ironmcm and Nalu l RewtKes-Division of Water Rawtuces Rei*cd Angusl P)B