Brunswick_Well Abandonment_20240624 (4)

«YELL ABANDONMENT RECORD For lnwmilLscONLY.
This form can be used for single of Inuhiple wells
1.W'e ll Contractor Information: W'F.LL ABANDONMENT DETAILS
Stefan Smith 7a.Number of wells being alunduncd: 1
WC111'nuiacwr Name(or%ella%ner personally;1bi donmg well an hellier properq) F.w Midople mlrrrlrm ,v ,na-«urer .1tp141 vielrc ONL► wuh the tcvnr
cvnom((i,#i ah�inrtrwro,rnl,irise trot%Ww"r,.vn•k,rm
3576A
NC Wcq CarsmcrnrCctrificalwm Nrrailscr
?h.Approtimate iolow(if wanc•1•remaining in ttcilist: igal.)
SAEDACCO
Ft IR%l a FIR SUPPLY W I.I.S.ONLY:
Conpim)Name -v. UN Ise of disirifectsint tined:
2.Weil CenstnacHus P«.lit k.,
llsr udl rrrgcf: ohlr well perm x(i.e.C'tmanv Skw.I arjawe hgeaitriir,eic.,it brawn
'd. %mount of diainfktanl u%td:
J.Well u.w(check:will use)-
Water Suppl Wdl: 7e.Staling materials uwd rc•lwck.Ail that apply):
❑Agrwulturd ❑i lunicipaUPttblic ❑ Ned Ccnicm 61":ol fd Bcntonuc Chips(N Pellets
❑Cieothenicil SNcantkWCMing,5iipph) ❑Rcsidoiti:d Water Supph ismFle) ❑ Said Cement(,rout ❑ Dn Clay
❑IndusinAl'omn)crcial ❑Rmidentud Water Supph ishared) ❑ (oncrcte Grimm ❑ Drill Culhngs
❑Im •uun ❑ Specialty Groot ❑ Gratel
Noe-Water Supply Well: I l Bedonite Slum 11 Other(explain under 7g)
Nklomtonne ❑Rccotcn
dejection Well: 7f,For each material w1leeted almi e,pros idc amount of materials owd:
❑Agmfer Recharge ❑Growdtvater Rcutedn Lion
OAgmfer Storagc aid Rccimen ❑Sahrun Darner
OAquifin Pest ❑SlornntalaDritrurge Bentonite.:lilb ,Wtr:gal.
OExprmmerual TachtnoloLn ❑Snbsidcme Control 7C.Protide a brief description of the ahaedonmeat prowdurr:
OCieothemral(CIosed imp) UTtacer
Pulled entire well and betckfilled with uncoated bentonite
OGeotherrisl Meaun 'Coolie Retuml [10ther4ex ain under 7u1
pellets. ♦"` 4
1.Date well(s)abandnncd: May 24 2024 6
Sa.W'ell location:
2 2024
lrifuiJC.9tRi.l ?'+ a�
Koppers Carolina Pole Site
Fecilip iOAMt Nair I >Tit InM iif applic nhlc? R.CtltilkalloCr: M���
1901 Wood Treatment Rd. Leland, NC 28451 `��1J(7/►w 5/31/2024
Nccedred well Commack r or well Owni:r Doti
Brunswick 8t .rigning then Jnrsi. 1 hereby cerq&Aw the well(s) was(werei aharrduned in
11 t­1 ktkiiiit�.tliuu No.4PIN) acrori ske with I1A NCAC 03C.0100 or X 021W Well Cunshvchon SUandurcls
and lhcd a copy of thin record has beets provkW to the well owner.
5b.Latitude and InnRitede in dcgrrevminutesAminds or decimal dcgrccs:
f it n cll fctd oix W limp r>uff.zmtl 9.Site diagram or additional well detailt:
34.250844 78 074457 You nim ibc the bail,of this page to prim ide additional well site details or well
N . W abandoontent detaib fort nun also attach additional pages if me essan.
CONSTRUMON DETAILS OF WCL S]i BEING ABANDONED SUBMITTAL INSTRUCTiONS
.n,xlr MrIJ cnareruclr+nr mrt�nJ.�N crvml�►5k•. !•rill muhrpk nyreLaur to rr�mMvrrr ra,Jq+ill -
*elk ONLY to jilt the mmw t wniret rxnr r>tivnknrnttmi.)ow inn athnrie woe Turin IOa. I;or All W'dlu Submit Iles form ttitlun ZU dtn's o1'completion cif will
6a Wr [D+e T "r_4 abandontncni to the follnteing
Ditision of Water Rexm)ccs.Information Processing Unit,
6b.Total Well depth: 13 (ft.) 1617 Mail Senice Cceter,Rakich,NC 2 7699-1617
Inb.Fur Inieclion Weill: In atldukm to sending the form to the address in 10a
6r.IkirehYkdiaerKhr l (in.) abate. also subnut one culm of this form within ?(I duns of compleion of well
abaidonnteni lu the follottuiv
MONion of W alcr Rcwouncs,I nAcrusound InJeLtion Control Prugram.
bd.W titer k•t el hrinw Lmnand surface: 6 (fA) 1636 Mail Senicc Centcr,Raleigh,NC•27699-1636
3 Inc.For Water Sumwll & InicctNin Wells: in addition to sendilgt the form to
6e.fluter casing Icn-gth lit Mow ni: (�) the addresses) abut c. also subinn one cop} of this form within 10 days of
completion of well abandon item to the :oanlN licalih department of the county
a h;rc atmrdoncd
6f.timer casin�'hibing len�4h(if I>nnts n?: {f9.)
6;.Screen length Of Wimi ri 1:10 (ft)
Farm GW-kit Non hCarolina Depanni:n of Ell uounncni and Natural Resmoces Re,used August 201z