Brunswick_Well Abandonment_20240624 (2)

WELL ABANDONMENT RECORD F,t lrgcrrc,l l v ONI F
This fomu can be used for single or multiple wells
1.Well Unntractnr Information: WELL ABANDONMENT DETAILS
Stefan Smith 7a.Number of wells beta;abandoned: 1
Well(•onnnow Name tot Moll o%no persnnallr ahankimng%vu on Itstlltet propene) F'!v wirloplr ttixtncur ur nan-«a(er .igyVi well< OND rah kilo ant
Coot<rmyt O,Nr!aly)rkt1MAl r-W,WN tot,"h)qW!Mt•-hirMt
3576A
NC Wdl Cnrentdot Ceti ifiulton Nnnixr
?h.Appro%imate volume of water remaining it well(s): (gtd.l
SAEDACCO
FOR WATER SUPPLY WMLS ONLY:
Conpan>Name 'c.'I'w pr of di.infectam used:
2.Well Construction Permit N:
LrJ rdl!q.f!ir.ird�! ueO,ern"', i v , !Wade..\7+Nr.ldrrawe brie,l,u!r.et, if A,mvn
'd. %rno(trot of disinfiYtanl uxtl:
J.Well use(check:well use1:
Water Supply Well: ?e.Scaling;material.used(cheek all that apply):
OAFncultunil ❑Munictp tlTuhlic I I Nall Cemcnn Gtonu 01 Acmomic Chips or Pclkts
O(kolhcrmvl(Hcanng-Cooling S14*}I ❑Residential 1b'aicr Sopph tsinLlci ❑ Sand Centem Grout ❑ Un Clay
❑IrdusinaU('ommcnjai ❑Resider¢tal Waier Supph i slut rcd) ❑ ConeteteGrout ❑ Drill Cuttings
❑frig tan ❑ Specialh Grout ❑ Grawel
Neu-Water Supply Wes: I I Betttouite Slurry I 1 Other 1e\plam under 7g)
E Monuonug ❑Recowrn
lmjection Well: ?f,For each material switicied alcove,provide•annuu l of materials used:
OAgmfer Rech W ❑Groundwater Retuedtaaron
ClAgmfer Storage and Recce-rn' ❑Sabrina Hamer
OAquifer Test ❑Slommvata Draitenge
Bentonite.:lllb ,Wtr:gal.
❑ENpertmemal Technology ❑subside ice Coni rul 71t.Provide a brief description of the abamidnument procedure:
OGeolhennal(Closed Loop DTvacei
Pulled entire well and backfilled with uncoated bentonite
Mwillieranl(HeatinpCooling Return) 00therilexplain under 7 l
pellets.
4.Date sours)abandoned: Hay 24 2024 r
Sa.Well location: '1
Koppers Carolina Pole Site if�v� `P•�r-
Facllm Ch<trr N;or, Facility IDA0(if applicabk _ _l 8.Ce11I11t ali0fl: �IM19"
1901 Wood Treatment Rd. Leland, NC 28451 5/31/2024
Phtsical Address.(n. i,::' •-.Ceotftcd Weil Counami of WCII O%m:r Del!
Brunswick lfl'.signtrix this furor, l hereby cerq&tha►the well fsl was(were)abanrla►red in
('ouw) I'.n.at la utilw:aKru No.(PIN) actwnho t•e with IJA XrAC 02C.0100 or X 0200 WWI Construction StrinrAml%
and rhea a copy of shra record lnrr beat prot4&d to the well owner.
ih.Latitude and longitude in degrrrominutrs;acconds nr decimal de-grers:
t l,tcu field.out Ln.long N uillitc ni 9.Site diagram or additional vskil details:
You item use the back of this page io prcA de additional well site details or well
34.250844 N 78.074457 W atbardonawn(deEads. You may also attach additional pages if nec:essan'.
CONSTRUCTION DETAILS OF WELI.IS►BEING ABANDONED Sl1BMMAL.INSTRUCTIONS
tfaxh well cnnrlru�)ant manr.h.:,7 arwha4fe 1•w multiple rn�rror,n air ergo-Marro w)y!h•
ttelkONLV with rlrr.atmetvma-w(unr!>•!cmah!r!mrnr tmcanahma,urrk!rm I11a. For AJI Wells,: Submit this forme %%ithrn i0 dar's of completion of well
6a.Wes IDs•TM'2 ahatdounicut to the following
Division of Water Resources,Information Prncrosing limit.
bh,Total well depth; 13 t617 Mail Seniee Center,Raleigh.S •2761MI-1617
(h.l
lob.For tulecti)m Wells: lu addition to settling the form to the address iu lua
above- also subout one copy of this form within 10 dins of completion of well
bc.Ilorrlvrrle diamahr;1 Idn.l arbatdonnretu to the following
lid,Water l-%el hrints grrtund 4jrfrrc: 6 (ft.) DhWon of Water Resources,Underground Injection Control Program,
1636 Mail Scnice Cewer,Raleigh,NC 2767946M
br.(inter casinfi Length Iif Imow nl: 3 (fit Irk.For Water Sua)h & Inicctuoa Wells: In addition to sending the forn(o
the address(esl itbove. also �,(tbnm outs coin of this fomi (within it) days of
completion of vwdl abardannent to the co(m1} health dcpanment of the coum
6f.Inner rasing+tuhimg lenLKh of I:nown 1:-(ft.) whore ahandoncd
6r,Screen length 1 if know n 1:10 A)
Fom)GW-In Noah Carotim Deponntror of Ent iroonteni and Naiwal Resowces-Dtv ision of Waicr Raotticcs Re%ised Augmsn 2t)I