Jackson_Well Abandonment_20240624

WELL ABANDONMENT RECORD NIT lnncmalV%CONI Y
This form can be used for single or multiple µells
1.%Vell Uvintr'acmr Information: WELL ABANDONMENT DETAILS
Brian Ewing 7a.Number of wells being abandoned: 13
tCctlt'•w:,u,tNanle lot%ella%IjLjpersojWhattan&jMlrgNrtl kill hn lrlpro[xml Ft nrulnplc nllrrrrror -w ,w.n-a<Ua•r 114p1Jr Webs ONLY vale they ,,,nrr
,'v,nlnta nr+n,rhowir.nmr•nt lor,tvvf mhrarr,ow Kim
4240-B
NC WdlCotutaanrCcnificalion NMmtrcr 71).ApprnniniAte t ulume of Nato nrm Lining in Aclip L• Cgall.)
SAEDACCO FOR WATER SUPPIA 11 I'l I.'�ONLY:
Compeer)Name 7c.Type of did 6etetast rated:
2.Wdl Cwtnretiou Peru It N:
fto,di epplaable well pertvttr n.e.(•recce.Sime.1 dndwe Ineeciutn.Mr..41Atn,wn 74L Aft of db)fafetitaat used:
J.W'dI use(check-w ell use):
R'atcr Suppl}Well: 7G Sadtalt materials u.cd(cheek all that apple):
❑Aprkultural ❑klunictpal:l'uhle; 11 Ncat Cement Groat I I Acn innitc Chips or Pellet.
[Xicothcmral IHcannj4+Cooling Suppl}i ❑Rc.tdctmal Water Supphv(single) ❑ Sand Cement Grout ❑ Dn CU%
❑hlthistnaUCommcrcial ❑Itcstdcnual Waicr Supph iskuarod) ❑ Concrete Grout ❑ Drill Callings
❑Leek olio ❑ Specialty Grout ❑ Gratel
Nos-Water Supply µ'ell: U Betitoolle Slurp 11 Other(explain utder 1g)
❑Munuonnc ❑RLcot cn
aj"tinn Well: ?<For each mAn•rial.c•icered abut i.part idc Amount of materials aced:
❑Aqurter Rcchsrge ❑Groundwater Retiredtatton
❑Agmler Storage and Recot en DSaluufy Harrier
❑Agmfer lea DSlortmalcrDratrnage --
DEspenntetual Trchnotiotin ❑Srbsrdctce Control - Foie 1&A brief description of tree ahAnfkrnmcnt p"Ketlurr:
OGeothemral(Closed loop) UTracer
OGeolhemral(HeanlivCooli Return) IOOl k:r lc. ain under 7 t BENTONZTE HYDRADLICLY PUSHED IP-B-1-25(ODDS)
4.Datewell(s)AhAndnnecl: 4-17-24 �16—11-o —
mi.Well krcation: r
Rays Grocery t[rid,;T.i.a!a?a-:-,w%*"4
it.Cerlifkatinn:
Faciliry,'pnneeName Facility IDN(if nlrplinbke) dlti-04904
1674 Z. Main St, Sylva, NC 28779 Brian Ew i n g 5/8/2024
PMsicalAddrim-Ctt, DW
Jackson BY.eigrrig this fixnt, 1 hereby certify rho;fine well(s) was(beret ahatidatted lit
Conan-. ac'c'ordame with 11A WAC 02C.0100 or 2C.02W Well Constrrrc•tion,V isnAirds
and that a cope of this record bar beets provukd to the well cnener.
51).I.atintde and Irurgitude in de2ne.,minutrc,.ectmd.or decimal degre•s:
+,tl ncl;lild ow Lit Nat_r,.,ullizici i 9.Site diagram or additional well details:
You mat use llte back,of this page to prep de additional well site details or µell
N W abatdonrneni details. You Ilia% alw,notch additional pages if nectmsan.
CONSTRU -nON DETAIL-S OF W'ELI1St BEING ABANDONED SUBMITTAL INSTRUCTIONS
.!(tech Mrl!cnnrinUant record•.:tl.n alas/a•. Fit mnhtp7r ogee crow,v arm-n.ttav zLlryit
MrikONLY with the acne,writrveranr rarhmo,,ow kwn 10a. For All k1 ell.: Stbnut this form nillim 10 days of completion of µ-ell
IP-A-1-25 ODDS abandonment to the follottrng
t.,t.RcII IUa: ( )
Ditision of%cater Rmtturcm Information Pniccssing Unit.
trlr.'final well depth:
13 1617%1ai1 Srnicr Center,Raleigh.SC 2 7699-16 1 7
(f1.1
lob. For lahectioa Walls: lit addition to sending the fora to the address lit Ilia
2.25 abut-_ alw srbuut one copy of this form within 10 loss of completion of µell
err.Rtrnhnle diantetot: (lu.) aba Bonn ew to the tbllowurre
red.W atcr keel bchtw Qrrrand wrface: (ft.) Disision of Water Rewfurces,Underground Injection Costrul Program.
1636!Hail Scnice(•cater,Raleigh,NC 276"-I&%
Inc. For Water Suarh .X Inkction W'eNs: In addition to sending the font to
tic.Outerca.ingIcnrthlif"fin nc Utc• address(csl abooc. also submit oak copy of this Wan within Ill days of
anupleltun of well abandonment n: the:ounn health depanntcut of the courts
u Ir;rc:fiandnncd
6f.inner casing-'tubing knLKh(if knnwnl:
6r.Screen Length of knowa1: Iles)
Fornr GW-40 Noah Carolina Depranniew of Ent ironntcin and Natural Rewunces-Dl,lsion of Rater Rcsoutcvs Rct Is"Aupsi 201 z