Harnett_Well Abandonment_20240617 (5)

WELL ABANDONMENT RECORD orinternall (�11Y
This fonn can be used for single or multiple wells
1.Well Contractnr Infur•matioe: WELL ABANDONMENT DF.TAIt S
Stefan Smith ` 7a.Number of wells beat;abandoned: 1
Well t'ouuacwr Nana rot well uwiar penoitalh abartloning well on lowlier propcmy i f.V reidnrd. nr(1(•••, d r,..-«.r<r .511.t41 .rN. ONIA .ith lit" "N"t,
r(dirmrr n.Ni.+Aan.Awm.mr l..r uo..ufwi(t.uir-6rrm
3576A
NC Well Cnraratar Ccnificatinn Naniicr 7h.Appro%imAtc tulum m e of water remaining in well(%)?l (ttr I
SAEDACCO FOR WATER SUPPLY WELIS ONLY:
Company Nanrr 7G Type of disinfectant uved:N/A
2.Will Ceeatructisa Pentnk N:,
L.0(di igylfn dhte weft Irrmri[r o.e.C nit.ShWe.I dnamire lnrrilmn.etc it kn"
?d.Amount of JisinFcctant uscJ:
J.Well ux(check-well owp
Water Supph Well: 7e.Sealin8 materials used(check all that spph):
OAgrncultnrul ❑Mtmictpal,Rtbhc f I Nc,l Cement Gram ® Remount:Chips or Pellets
OCicothemal(Hcatrm Coelhoe Supply 1 ❑Restderatal Waler Supph'nsmFle) ❑ Sand Cement(horn ❑ Dn Cla}
OlydustmaUC'onuncnral ❑Rmidctmial Waicr Supph ishared) ❑ C'orn-reto Grant ❑ Drill Cuttings
Oltti •Bull ❑ Specnalt., Grout ❑ Grate)
Nos-Water.Supph•We*: Ll Nitionne Slum Ll Other(explain under 7g)
➢9MuuvonuL ORa:osen
Injection Well: X For each amer•ial sckcted aho%v,prntirle anwvrnt of materials used:
OAquiter Recharge ❑Groundwater Rentedmiton
❑Aquifer Storage and ReccAcn ❑Salnun Barter
OAquiferTest ❑SlonmtatcrDriimge Bentonite. :71b ,Wtr:gal__
OErpenmenlal icclmolog% ❑Suibsndcrice Control 7Z Provide a brief description of the abandrrnment pnictdur:
OGeothenral(Closed Imp t_ITracer
I ICioDthemtal(Hc~ntn>;-Coolie Remm) I I0ther4cc abn under 7gt Pulled temporary well and backfilled boring w/ hydrated
bentonite chips from th,B bottom up.
4.Date w clloo abandoned: 5/20/24 • `•�n1,.R Y & ..
��'ell w�alinn: UN 1 7 704
W. Cumberland St. PCE Site
I,lciltl) (h11..1 lo- FecibryWo(if applicablc) R•CttlilkalNwt: {r�jjS7E4�FPrl 7'^(MR Urd
DYIrQf 3Ci1 j
1200 West Cumberland St., Dunn, NC 28344 04
5/27/2024
Ph.,sisal %ddress.Cm.aid Lip Wild:
Harnett tfi-.vig ning thcs)tww I hereby early that the wellfs) was(were(ahafirloned in
V-ii cl ldeuufa:nmoi No 1111%1 acturthux-e with IJ NCAC 02C,0100 or 217 0:00 Well ConNhwcbon Vaadardx
and that a cryry of dus record haw been pnnwkd to the well owner.
Sh.Latitude and longitude in dtvvvvlminurd•vhcconds or dicimal degivirs:
ell tell i"old one Lit Yln i•.viJf is sit 9.Site diseram or additional well details•
You vial use die back of this page to pro ode Aittional well site details or well
35.314064 N 78.622259 W abardonnnenu details You nn:is also mtach additional pages if neceasan
CONSTRIA-rION DETAII S OF W'EL"Sl BEING:ABANDONED S iBMiTT L M iCTiOYS
Aflaclr aril ra2rJrl(.L+•.(mend x(II u<ruLd.k. I'ur MLItlr1('!llli Lt101(qr(J-j m'tlter xwppl l
Welk ONLY wifh the+lime(uRsoi non iifian6iittnmt,i+w can vrhnrit rune hmn. Iva, For All %N ells: Subnul This form within 10 da%'s of completion of well
611.Well IDO:TM-1 ahandminicni in the following
Disision of Water R"mr-cm.Information Pnwnsinng Unit.
61).Total well depth: 23
1617 Mad Senice(''enter,Raleigh.NC 2 7699-1 6 1 7
ifLt
I0b.Fur Inicctlon Wills: to adrhuon w sending the fonn to the addncss to Ir1;i
abuts. also subnun one cofm of ilus fonn within 30 dins of completion ut dell
1w.B wOuile diameter:1 nin.l abandon melt to the tollouini.'
Disisioo of Water Rtymiurces,I.ndcmntund Injtctirin Conlnil Program.
6d.V1 ah r k srl Irrhiw ground wrfacc: 12 (ft.) 1636 Mail Service(enter.Rr1eith.NG'27699-I6J6
8 Inc. For Water Sutrnh& Inkctlon Wellit: in addition to sending the fomr to
tic.Outercasinr length of knonnC (�) tiic addressiesn abote. also stibnnl one cop} of this font within 10 da)s of
completion of null abjmkin rent to the count health depnrrunciv of the counin
n here abandoned
6(.Inner ravin�'tnhinE kni.Rh IiF known(: tft.►
6d.Semen knkth(if known 1:15 (ft.)
Fomu GW-V1 Non Cambria Depannaan of Em womueni aid Natural Rewruccs DiN isioe of Water RaourcAn Res iced August 201 a