Brunswick_Well Abandonment_20240624 (5)

NVELL ABANDONMENT RECORD For InwrtiilUscONIY
this form can be used for singk or multiple wells
1.Well Contractor Infirrntatiou W'El.l.ABANbONMENT DETAII C
Stefan Smith 7a.Number of wells being abandoned: 1
we11('4111113Ltor Name tot well ureter perAmWl.N abanitanutg well an halter propent r F,w misled, auea,uu, .w +wa+-.tarer nyy4i wM( ONLt rah Nee sixty
r,tminyrn,wt+d a nhutm,mr,seta c}ar a+baur wrr h,rnr
3576A
NC t4'c1lCnmridnrCctlificalinnNnnbcr
?h.Approximate►olerateof ribs remaining in well(%1: -,gal.)
SAEDACCO FOR WATER SUPPLY WELLS ONI.Y:
Compare Name 7a Type of disinfectant uwtrd:
2.Well Cwtnisictbn Perini M:,
1jm.d1 mWkuh1r well permaa me.CwnA,Use.I ariawe Igtei1mov,estr.,it Amwn
7tL Amount of disinfectant iced:
3.W elI six(check w all ase):
Water Nuppl% N ell: 7e.Staling mate ia1%u%ed teheek all that applt):
❑Agnculturil ❑Municipal:Pttblic ❑ Neat Cement 01"mi pp Actionnc Chips or Pellets
❑Geothermal(Hearing'Cooltnr Supph't ❑Residential Water Supph tingle) ❑ Sand Cement Grout ❑ Un Cb—,
01ndustnal:Commercial ❑Rcsidemtal Water Supph n shared 1 ❑ Concrete Grotto ❑ Unll Cuttings
❑Im •tutu ❑ Spectalt}Grout ❑ Grdxel
Nos-Water%upph Well: 11 Berionite Slim I.1 Other w;plam under 7g)
Skluntto ring ❑Recover
Injection Well: 7f.For each matrrial wclected abate.pt i%A—momaint,tf materials awtd:
❑Agmfer Recharge ❑Gmutdwater Rcntediatton
❑Agtafer Storage and Recm cm ❑Sahrutt Banter
Bentonite. :lllb ,Wtr:gal.
❑Aquifer Test ❑Slonmtater Drainage —
—
❑Erpenmenlal TeclmoloK% ❑Subsidence C'oniml 7g.Prmt ide a brief description of the abandonment procedure:
OGeothemtal iCbsed Loops LITracer
Pulled entire well and backfilled with uncoated bentonite
OGeotht:mfal(Hearin 'Coolie Retum► [Other ic>: sin under 7 t
pellets. r, -
T
4.Date wells)abanolimed: May 24 2024 %`-- ., .
Sa.Well Mtcatit►m: JUN 2 4 2024
Koppers Carolina Pole Site IIIAK l'W►VA Arft, `Vn
Fxrlm(ocnerNaaw r,.;r1, 11 �:.'i,t,it. 11, S."Crnifkation: �11d
1901 Wood Treatment Rd. Leland, NC 28451 5/31/2024
Phc steal Address.Cu,..a�f r n: S �utn •.Crntlicd W'eg Cnatrxmr or Wt/Uwtser l]:r.:
Brunswick At .signing this fmm, 1 hereby cerb#-thm the wellfs) was ftrerer abandoned in
Rime)ldtruilRaooti No WlS i accorwhsace with I1A MAC 02C,0100 or 2C OM Well Construction VandunEx
and that a dopy of&is record has beers provided to the well owner.
th.Latitude and longituffc in cicgtrrs,1minu[rslsccnnds nr decimal dq;rccs:
t,«r(Elul ;;tr Us w,tt•r..rdnc>*; 4.Site diagram or additional well cktails•
34.250844 78074457 You nim use she back of this page to prof ale additional well site details or well
N . W abantdotumni details. You rein also attach additional pages if nec essar%
CONSTRUCTION DETAILS OF W'ELL(S1 HEM;ABANDONED SUBMITTAL FNSTRUCTIO14S
Aikkh"ell iomvNadfw recur.(-.v it avwhatik•. t•.v malnplr ayta riser,v ream xvfrr nr,!r�,
welkONLYwithrheaunrtvmrrarromaA(vnkswmmr.iwcansubmilone.1afm Itta. Fm :VI 1lells: Suhnut this form within 30 da}s of completion of well
6a.Well IUa-TMW-5 :nbatdoonicnt In the follouing
Division of Water Resource,Information Pnicessing Unit,
66.'Intel.r ell depth: 13 (h.l 1617 Mail Service('cuter,Raleigh.NC 276%1-1617
lob. For Irlectieu Wells: fit addition to sending the form►to the address in Ilia
abo%c. Aso submit one cop\ of ton form milim 10 dins of completion of well
6c.Sur ivoic diameter:1 tin.) abandonment to the followutg
Division of Water Rewturres,I n(Ics•ground Injection Contrail Program.
tiff.Water Ievel below ground wrfaee: 6 (ft.)
1636 Mail Service('enter,Raleigh.N('2769Y-1636
3 litc. For Water Svpol% & bokctMom W'rN%: In add r addition to sending the form to
tic.Outcrcasingletrigthtdlmsrwal: (ft.) the address(es) abme. also subnih otk cop% of this form within On da)s of
completion of well abandorumni to the count-, health department of the coutth
6f.Inner casinv'tubing length cif I:now n l: ift.l a lvrc abandoned
6g,Screen IcnLih(if t,nom n r 10 tft.l
Fom►GW-Xi NookCarotina Depcnur:ta of Ems irotimem aid Naimml RcwmKcs-D%isron of Water R,sommes Rc.red August 201 A