Jackson_Well Abandonment_20240624 (13)

WELL ABANDONMENT RECORD ror Infernal ONLY
This form can be used for single or multiple Aells
I.Well Uann•aetnr Information: W'F.I.I.ABANDONMENT DETAILS
Brian Ewing 7a.Number of wells being-abandoned: 13
Well CoWraeltu Naar:rot aacll uwLLY Wisonally abandoning well on het/let property t F'.o Mldoplr nNerhrur .w ,r..i-writer ruptd% veils ONLY wah ilk, .wnr
r.m<rnrrn,wr, amhmm.mr,t„w(YDI w„bm0t..n.-6,rm
4240-B
NC Wcll Comwctot(7c"MicaWn Nntt#icr 7).Appnnimate volume(if water remaining in%%ell(wk 1gal.)
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
Convent)Name 7c.Type of disitifectant used:
2.Wdl Coustntetioa Patitk N , WI0100715
ba rdl tpptavhk weN perenta n.e.Comas..Sneer,I'anawr hi;eoirm en. ,1 k,rnwtr —
7d.Aetoeaf of disinftYtanl uxd:
3.Well use(cha-ic wall use):
Water Supply Will: 7r-Sealing material.uwd(check all that appl l:
❑ARncubural ❑kltmkipal;Public CI Neat Ccnicut Gooier I I Hcnlontic Chips or Pellets
OGcothcrul(NcatingWCooling Supph I ❑Rcsidcivial Water Supph (single) ❑ Sand C'cmcoa Grout ❑ Un("UN
❑hodusinaLCotnmcrcial ClResndctatal Water Supple nshatr d) ❑ Ccmctcle Grout ❑ Droll Cuttings
Elittigalloll ❑ Spetaalty Grout ❑ Ciraacl
Noe-Water Suppl Well: 1_1 Beniotute Shorn I 1 Other 4eyplan)under'g)
❑1%tuntonuL ❑Reco%en
Iejcetion Well: 7f,For each material selected show,provide amount.,f inaterish aged:
❑Aquifer Recharge ❑Growd,.%ater Rentedi:uton
❑Aquifer Storage aid Recm en ❑Salttutt. Hamer
❑Aquiter Test ❑Slorn%ater Uratnagc _ _ -
DEsper nwntal lechooloey ❑Subsodeme Contrul - Pi.,%nde a brit•I do criltion of the abandonaicnt protedurr:
DGeothern al(Closed I,00pi UTracer
BENTONITE HYDRAQLICLY PUSHED IP-A-2-26 (EVENS)
DGeothemial dleatmg,'Coohug Returl PQOft r 4 c\plain under 7g f —— --
{{ R k
t.Date ut-M-labandnned: 4-18-24 JUN 2 ` Z02
Y
ia.Well location: 1�14
Rays Grocery D' Q .rd
FaGilay'Own:r Nano Facility LAN(irapplicabtc?
X.( rrr,lir.rtLuc
1674 E. Main St, Sylva, NC 28779 _Brian Ewing 5,e,2024
PM'sical Address.Cii, DOW
Jackson 13t sigerpg(thew fr»m. 1 herekv certr#thm the irell(s) was fueret abarndowd in
Caaooy Flan)Iderdir"Itoll No (PIS r accunhtru•e with IIA?CAC 02C.0100 or X OXV W641 CiovL rtrchon Uimclnrxis
and that a cope ojdris record has beery provided to the well owner.
Sb.Latitude and lingiturl•in rbtymeslminutrsi%tctmds nr dtcimal degrees:
u,crt�Id :,,�t:rr 6•q:„.utt,. ,a; 9.Site diagram or additional well details-
You ma% use the back of this page to prcn ode additioiral well site details or well
W abanikmi tera details You rnaN also:wach additiuual pages if necessary
CON',]RI C I fO\ DIA >< 01- C11.1 I,,�,i BEING ABANUONFD SUBMITTAL INSTRUCTiONS
:Usk. .,. mulxhple ovecnuir „ ;;r•i,
weldvQNLf w,urf>r..,,,,rr,N,.,,,at n,m�,Wntr„�„�,tr.�.�,cuterxAttatwrrJr,me' boa. For .all Welk: Submu this form milom 0 Says of contplction of n-ell
IP-A-2-26 EVENS ahaodanniew to the Winking
r,a.%\.•11 lib=- ( )
Division of Water Resnurcm,Information Prucersing I nit.
1617 NIA Smice Ginter,Ra ?
ub. I„tab ell depth: 12 (ft.► legth.NC 2 7599-161
10b. For lelediou Wells: in addition to sending the form to the:iddivss rtr loa
nc.Rrrrrladr diancetri.2.25 (ie.l abw%e. also subutil one cope of[his fomo%%illun ;0 days of cuniplction of cell
abandonment to the lolluauig:
Di%isinn of Water Rvomrre.,Cudcrunrund Injection Coetrtl Program.
tot Water Irvti heliw giround suKarr: (h•) 1636 Mail Semite Center,Raleigh.N('27W)-1636
Inc.For Water Suatl & Ink•On:li 'ells: In addition to seeding the fonu to
fir.0 toter casing length 4ifImnwel: (ft.) de address(esi abo%e. also submii one cop% of this form %%ithm in dms of
.ouipletion of%%cll abandonment to the count% health department of the.our
%%here abandoned
r,(. Innercaani�uibin_Irn�Kh doI.nn%aui: (H.1
log.Scrum lenoli!if know n r; (fl.)
Forin GW-tor I� rurZol W 1 !tin aid Nowat Rcsowts-N%iswn ol`Warcr Reiour�r, Rea sed August 2%01 t