Jackson_Well Abandonment_20240624 (10)

NVELL ABANDONMENT RECORD For lracnetlCscONLI'
This form can be used for single or multiple wells
1.%'ell Cnntrartnr Information: DELI.ABANDONMENT DETAILti
Brian Ewing 7a.Number of wells being abandoned: 13
WeltCounacim Nape(ot%ell uhtw7 penonalh atuntdomng well an htc;ler propcny i F.u• t 1drif.c tnletlttot V• owj-oafee elfs ONLY trh lhe• nowt'.
4240-B
NC Wtl1 ComnetorCenificalion Nnnttter
,h.Appn)yinuh rulume of water tcnuiaing in well(st:
SAEDACCO
FOR%%x 1 ER SUPPLY WELIS()NI.Y:
Contpatn Name -c.l.Nlie of doinfe tans used:
2.Wdl Ctatstttactioe Punk#-, ,
Lst,dl tµy4icahk well permifr ri.e.('wMY.Sade•(Art v byetlina•rtc.j if kin-,
'd. \mount of disinfiYtant used:
I Well use(check well use):
Water Supp1,% Well: 7tt Sealing materials used icbeck-all that apply"):
❑Agmultitrd ❑Mttnicipal"Public 0 Ncat Cement Groot ❑ Hcnronitc Chips or Pcllcts
❑C'eotMtmhl eHcaeing+Cooling Supply) ❑Residential Water Supph ismFlc) ❑ Sand Cement Grout ❑ Dn CIA.'
❑bduSITIMA'omtncrtaal DResidertial Water Supph isharod) D Concrete Grout ❑ Doll Cluhngs
❑Irti 'uon ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: Ll Bentonile Slun) I)Other Iesplain under 7g)
❑NIontionna ❑Rccoven
Injection Well: 7f.For each watetial selected abov'tr,pre%ide amount of materials awed:
❑Agmfer Recharge ❑Grourdwater Rorwdutton
❑Aquifer Stotage and Rcco%en ❑Salrnn Hamer
❑Aquifer Test ❑Slommyater Dratnage
DEM. x imenial Technolop ❑subsrdctce Control ^g.Prin ide a brief descriptittn of ire aranMuen ow procedure:
DGeolhermal(Closed Loopi ❑Tracer
DGeothermal Meatin 'Ctotilin Return) MOtherilexp4ain under 7gI BENTONITE HYDRAO'LICLY PUSHED IP-8-1-25(ODDS)
t.D'atewrllist ahandnurd: 4-18-24
ia.\Fall location:
Rays Grocery i(Av't1CJiiiffvri `�a
F,iohn (htiKr Niow F-101m IU n(apFlr.-;ih1��7 M.1.rrlittcaptnr• y/AQ1104
1674 E. Main St, Sylva, NC 28779 Brian Ewing 5/8/2024
Physical Addrcs.Cih.and Zip Syynpan o(('ertified wen Cnrtttapnr::r y:Y t�rtRr Date
Jackson By sigmag this•form, I hereby certify Thal die wellfs) was fwerei aherodoned to
Comm,. Paned IAen"\!radon No.(PIS t auvrdaw-e with 1 SA MC1C O:C.0100 or X OI00 Well Comvi'ructiovr.9',rm rmlx
and that a avpy of this record has beer;prodded to the well awner.
5b.Latitude and longitude in dcMvvmiouteshrcnnds or decimal dvygres:
?t1 null tclJ um hn k>ng t..n lit�watil 9.Site diagram or additional well details:
You nun use the back of this page to pro de addition zit well site details or well
N W abardonnreti details. You tua% also atach additional pages if neciessan-
CONSTRUCTION DETAILS OF WICLUSI BEING:ABANDONED SUDNIMAL INSTRUCTIONS
.lrruch aril LYlR1"L9tC lrUtf n•cr�nNs:ll Jl'mlutik. hcv far}(7}flC UiK'C hHf!ry arm-MaEi7 xrppir
*vIk ONLY otithMem~cwtoraLworuhtmkxwx u.iwcoamhmuarekwm. IUa. For All Wrlis: Submit Ihrs form aitrin 30 da)s of completion of wall
IP-B-1-25 ODDS abatdonnicn(In the following
t��.1\all Iha (ODDS)
Division of Water Resourm,information Pn;crssing Usit,
t6t7 Mail Service Center, NC 2 7699-1 6 1 7
hb.'futnl well depth: 13 (d.) ���
lob.For taleettoa Wells: fit addition to sending the font to tlw address iu toa
oc.Rttn'ladr diameter.2.25 abuyc. also submit once copy of this font wnlio it)d:ns of completion of well
(ln) abandonntcnt to the follm%in!,
Division of Water Resources,Uathrgntund Initx6ov C'oatrol Program,
wl.M Ater kw'rl bclnw ground wrfare: tfY.) 1636 Mail%mice Center.Ralm--tn.NC 27ti9 46.36
l0c.For Water Sum)ly & Ini ction%'ell%: In addition to sending the form to
oe.Outer casinglengibOfknowat: (ft.) the addressees) abuse. also submit one copy of this form within It) days of
completion al'well abandonment to the couniN health department of the county
6(.timer casin;!4ubing knLah(if known): eft.) aiicrc atvindonncd
tog.Screen length cif brow n
Fotnn OW-In Noah C'ambra Depannwo of Ens oonnicni aid Nattoal Rcsowees-Dt%isnon of Water Rc'sou vs Revacd Aupt9 200