Jackson_Well Abandonment_20240624 (11)

WELL ABANDONINI ENT RECORD For lroemil Usc ONLY
This form can be used for single or mtdtiple wells
1.Well Contraclnr Informatioa: W'ELI.ABANDONMENT DETAIL 4
Brian Ewing 7a,Number of„ells being(abanduned: 13
Wall Coarracam Narm(or Nell oNttet pets.oull)alaaadoruag%e0 on halter proper)I F,w mxlopk oueoow or w x-tcMer styrh weM ONLi +.rdi Nk• ,con,-
r'!Vtom,n,.w ahawhwm,'nr,lvw(Yw vwkwo are F+rwt
4240-8
NC Well ConlmaorCeiNfi�itino Naniticr
?b.Appruritnate volume of water remaining inMilled: (Ea1.1
SAEDACCO FOR WATER SUPPLY WELLS ONI.\:
Conpin)Narm 7c.Type of dlalnfectart mud:
2.Wdl Ceustmetion Peewit 0:
Lu,dl+gyGtan6o,U ,r , a!nn.Ptah-,litrkameln/euttotr,ere.,ill<m!wn 7d,Allotment ofdisiufeetantused:
3.Well use(check n Lql"set:
Water Supph Wall: 7a Sealing(material.used(check all that apply):
❑Agnculturd ❑Mun icipaUPuhlic ❑ Neat Cenicur Groat I 1 Beritonite Chips or Pellets
❑Cteoillizi it eHcanng-Vooling;Supplyl ❑Restdcriri it Water Supph isingic) ❑ Sand Cenoew Grout ❑ Un Clad
❑hdttstriaU('om111CMal 011"(1ciuud Water Supph isharcd) ❑Concrete Grout ❑ Drill Cultings
Ellnismicill ❑ Specialty Gtutt( ❑ Grakel
Nom-Water Supply W'cll: ❑ Bettlonite Slum I i Other(explain unider'g)
❑McintuonnL ❑Rcco%en
Injection Well: 7f.For each nnaterial wlected altme.linnidc•itimmul of materials used:
❑Aquiler Recharge ❑Groundwater Reniedtation
❑Agmfer Storage and Recce en ❑Salina% Hamer
❑Aqutfer Test DSlommatet Draituige --
❑Espenntenlal Technology 13subsidcnce Control 711.Ruside a brief descriptirrii.i(th,c,rbrnelonnicnt procedure:
❑Geothenilal(Cbsed Loop) ❑Tracer
OGeothenilal(Heatin 1Coolill Return) 190(herle\ ainunder7 ) BENTONITE BYDRAULICLY PUSHED IP-C-1-25(ODDS)
„r.
4-Date wcllis)ahandoned: 4-21-24
9 UL�+
ia.W'eB location:
Ire(+iS'nrar..it,• 9•—:MM�L s'.3xlt
Rays Grocery EYA-C d IC o'
Facillt)0A"Cr Namc I —tn Illetifapplrahlci i•Ccitificatian:
1674 E. Main St, Sylva, NC 28779 _Brian.Ewing 5/8/2024
Physical Address.OtN,aidZip SidrrltrrcPfCenfffCdWCIICon+t,i,i , ,::00wter Dale
Jackson 1h.sigatnCq ncLrfixtnu, l hereby certify that the wwfi(s)was(werei ahmidoned in
Corot) I.heel l&I113fkAb(m N,, WiN t act-onkm-c with MA?CAC 02C.0100 or 2C,O2 O Well Conshwctlon Sfamkonls
imd"o cvp,aj this rerord has been provided to Ike well owner.
Sb.I atifude and Inn1(iMdc in dr>trreslmilwtesiaminds or decimal degrees:
(it Nell field.sac•Lit:l mg M♦nlitcsov) 9.Site diagram or additional Weil details:
You ma) ire the back of this page to prmide a"hotial Well site details or hell
N W abatalcminleiu detain. You dilly a6ci;"tack addititmal pages if nec essan
CONSTRUCTION DETAILS OF WEWSI BEING ABANDONED SUDMiTTAL INSTRUCTIONS
loath well rortciritdr ai rrcnr.l.sr{!seals'+Jr htr mklnplr ogee non or nice-wawa •nl!rii
vivIkONLY with the a.krrcwntrrctk n ahra Awmrnl.i.w can swhmi core N m. Isla- For All Welk: Suhrml this form withnn i0 days of contplcliou of well
Nell Ipa
IP-C-1-25(ODDS) abandonment to the foliowitkg
Dilision of Water Resiturre+,Information Pniccwdml Unit,
nlr, ohdNell dcptic 13 1617 Mail Senice('cuter,Raleigh.NC 2 7699-1 6 1 7
'l (h.►
lob, For Iaitediom Wdls: in addition to scitdmg lire form to the address tit lua
2.25 abo%c_ also submit once copy of this forin within Ili tans of completion of well
III-.RiinlNdc diania•tcr:` (in.l abandonnictu to the following
MhAouof Water Resource•.,I odemritund Injection Conind Pnigram.
lid.Water k•iei below ground surface: Ili.) 1636 Mail Senice('enter•Raleigh,NC 2?699-106
ltk. For Water Suntnh & Iniectkro Wells: in addition to sending the fonn to
I.e.Outer Casing length l if lemon n l: (ft) the addressees) shone. also submit olle cop) of this form millin tit tans of
completten of wdl abandoritnent to the count% health depanmen i of the Colin"
t&inner casin-_-'tubing MnLah of kooa where almndoncdssn►: IH.)
fig.Scrcen length(if knowni: eft.)
Fomi GW-tit Nonh Catohin Depannnd of Ein irounknr atd Natural kesolmes-Di%ision of Rater Resources Re.eed August 201 i