Brunswick_Well Abandonment_20240624

WELL ABANDONMENT RECORD Fotltnern:ilVWONI V
ibis form pan be used for single of multiple wells
t.Weil Uantractur Information: WELL ABANDONMENT DETAi1 S
Stefan Smith 7a.Number of wells brunt abandoned: 1
Well Couuacror Nanie tot well owner personally abandoning well on halker proper o F4W ixwinrie allecnmf fir rani-wduee sirpph wells 0 M .irh Nh• +wnr
,.n+rrrr�hex,�d1�iahwmrnr. i.,u„nr.»h»ut wfr 61rm
3576A
gat.)
NC Wcll ConlntuorCcnffiratfon Nnniticr
'h. \Igorrnioi,ik „Conk 1 n:ucy remaining m iscll(si: I
SAEDACCO
FOR"\1 i R S I PPI 1 N ELL$ORLY:
Company Name -c.T,.pc of th,infcctam used:
2.Welt Coustltctiirn Pt emit M:,
i ou<dl„lr�fr:,rM14 ae7!lw rir,Cs i.wnfr.SNMe,)tlnWK'e trrrrdiuin,etr.i Jbrown
?d.Amount of diwnfctitanl used:
J.Well use(check:wall use):
Water Supph Well: 7e.Sealing materials used(check all that apply):
❑Ag anilturil n-%itmtcipal/Ptibiic fl Nchi Cement G"it ® Rcrvonitc Chips or Pellets
OGeollicmvil(Flcanng C•oohng S-4tppl%1 ❑Rcsi(ciaial Water Supph mingle) ❑ Sand Cernem Gran ❑ Un Clay
OlydustrialrComntcn a! ❑Residemtal Water Supph ishared) ❑ Concrete Grout ❑ Drill Cuthnp
Olrti unit ❑ Specialty Grout ❑ Gra%CI
Nos-Water ltrplih Well: 1 I Bentonite Slurn i l Other tetplain under 7g)
Nlvlotulontw DRecocen
Injection Well: 7f,For each ntaa•rial sc iccted ahmie,prinide anoint of materials used:
❑Agtpfer Recturgi: ❑Groundwater Rcntedi:uion
❑Agml r Storage aid Reco%try ❑saloon darer
OAgtnfer 71eu ❑Slomnsater Ureuutge
Bentonite.:lllb ,Wtr:gal.
OExpenmenlal TochnoloK% 0Subuclk4we Cotarul 1g.Prvride a brief description of the ahandnomto procedure:
DGeotherinal4Closed Loop F ❑Tracer
Pulled entire well and backfilled with uncoated bentonite
OGeathemttd(1Ki�tin oalin Return) []Other le sin under 7 )
pellets. �- «
3.Date welivo abandoned: May 24 2024 a+._'� •t
5a.Well location: JUN i 41024
Koppers Carolina Pole Site law tatwaeil 70 *W-;L4%1
R,Cetl4fkatien:
Facila►T_l%sncr Name Facility(INf(([applicable( j3MhCd'lCvir
1901 Wood Treatment Rd. Leland, NC 28451 5/31/2024
m Ph%sisal Address.C ,aid Zip �� reauiod wetl fa>peocmr or w'etl omttLr U,:::
Brunswick By signing this fam, I hereby certify than the we11(s)was(were)aharAdaned m
Coaw) hares(Idewification No.(PINI a(xonhatca with IJA!CAC 02C,0100 or 217.02W Well Conetmelton Stfirickirr/.r
and that a copy oJthis rerrird/hry been provided to the well owner.
Sh.I.atitude and kingituik•in ekgn rehninuresfscrnnds or decimal degrees:
iJ ri el:fill.o,><Lu.wind 9,Site diagram or additional*tell details:
34.250844 78.074457 You imn the the back,of this page to prinide a"hottal well site details or well
N W abatdotinteru details. You nun'also atlas h adilitiutu►l pages if rtectasan.
CONSTRIK-TION DETAILS OF WELLiSi BEING ABANDONED SUBIIRTTAi.INSTRUCTIONS
tftduh"efl LdIA.Y}fl,o-i mvirthsJ!l atwhdile, l•(.v milople nyecnGw or *in-wuw-NIA,
*Wk ONLY with elk•t,»iwtvmvwWWd4NkriMe"1.1*W cdrn Sntinnt mwf)m l0a- For All kkells: Stihmtt this font within ?0 dms of completion of sell
6a.N'eB(Dir•TMW-1
abardennicnl in rlk-following,
Dhision of Water Resnurres,Information Processing Unit,
61).Totat*tell ikplh: 13 (tI.) �
1617 Mail Sera ice Center,Raleigh.NC I7699-1617
lub. For toiecliom Wells- In addition to betiding the form to the address no loa
abu%e. also subnnt one LqA of this form Within 10 days of completion of%sell
6r,IktrcMhlc diameter:1 (lo.l abardonnictu to the following
Disisiom of Water Resuurres,Under gnound Injection Control Program.
bet.W'atrr level hell* g±trruud surface: 6 (ff.l 1636 Mail Senice Center,Raleigh,NC 276"-1636
3 Itk.For Water Sumtlt & Inittion Wells: in addition to sending the form to
ire.Outer casing Irngth lif knon ni: (ft l Ili, addresses) above. also submiu one cop} of this fort within il) days of
completion of well abandonincm to the coumy heakh depanmera of the county
(of.Innercasin>r+tnbiag length Iif knaNn): (ft.) a lists atmrdoncd
6g.Scretu length Of known):10 (fL)
Fort GW-:Ni North Catchaa Ds fvn nx N of Ern irotiniew and Natumi Rcsomes-Dn ision of Water Ro iouives Re.rsed August 29I I t