Jackson_Well Abandonment_20240624 (3)

WELL ABANDONMENT RECORD For lnterml Use MY
This form can be used for singk or multiple wells
1.WeN Contractor Infurmatioa: WFLI.ABANDONMENT DETAILS
Brian Ewing 7a.Number of ad is brlrt8 abandoned: 13
Well Coauacrot Nang tot well owuY perwoolh ahamdoning Nell an halter proper m F.v ,wit!opi, trrletluot ,,r w,o-omer riq nh rMs ONJLj rrrh rh,• .,uric
"14tarrnt fNar at4LNt,NMrerrt,ir,q,rur,N!VH//Nt.•F,rn,
4240-B
N(�1tr❑('amnct„r<.cnui._nrnr huni,a
7b.Appmxbnate vabmw of water rrmaiaing in Ndl(tl: (gal►
SAEDACCO KIM WAIMR$UliM.Y WELLS ON1.V:
76 Type of di-Anfectant used:—
2."ell('ntntruction Per-mil 0:, W10100715
i ,, i"IX, �.wrtf,. \},N<•. n dnd,K<• ln;rdirar,ek.l tfkariwir
74,Amount of disinfectAw used:
3.µ'ell use(check well utcl: —
WatrY Sapp)} N't•II: 7e.Sealing materials wwd(check all that apple):
OAgn uloural ❑hlumcipal,Publtc ❑ Newt Ccmcm Grown (l Hentonite Chips of Pciktt
136cothcmal(Hcangg Cooling Supph i ❑Rcsukrvtal Water Supph(single) ❑ Sand Cement Grout ❑ Dn Cla}
❑Indusnnal,'Comntcrcial ❑Rrsidervtal W'atcr Supph Islwted) ❑ Concrete Grout ❑ Droll Culimg+
❑Im •tmou ❑ Spectidh Grout ❑ Gra\el
Noe-Water Supph Well: t_l Bentonite Slurn I 1"her(e\plain under 7gi
❑hhimlonne ❑Recoten
Is*tinn Well: 7f•For each material wlectcd above,proaide amount of material,,nerd:
❑ALImler Recharge ❑(itUundwJler Remedlation
❑Agmter Storage aid Rerv%cn ❑Salmon Banner
❑Agnrtd'ILLA ❑Slontmaler Drairwge --
DExpenmenlal Teclusaloln ❑Subsidence Coiaiol
Prrrrirk a brief description of thr ahandtmrricnt pnicrdun:
ClGeoth meal(Cbsed Loop) LlTracer
BENTONITE HYDRAULICLY PU D, IP-C-1-25(0DDS)
I lGeothermal ftfifingiCooling Return) IOOthcr(explain under 7 )
1_Date weiii)ahandinmcrlc 4-21-24 JUN J 2024
Sa.Well location: — w UO
Rays Grocery
Fxrlq�•Oancr Nalm Fxflitc IDM(if applicabk) 8.Ccrlilkati,in:
1674 E. Main St, Sylva, NC 28779 Brian Ewing 5/8/2024
Ptn'SiW Addles, i.i, Siw,t Iw, A I. Dare
Jackson Rt•signing this fmw I hereby cerhJy that the well(s)was tirerel abandm of in
Corih I.accl kkriiiticati a No WIN urvo►thtnc•e with ISA T7AC 02C.0100 or.1C 0-100 Well Corrstrurtton S(ondirn/.r
and that a(.tip r Ojthis record hru bef.7i prrn•ided to the well owner.
Sb.Latitude and loncittedt in or decimal degrit"
ni,.cli ILId art Ln I,ar i.,alir,ur>tr 9.Site diagram or additional well&-in s:
You mai the the back of this page to prcn de additional well site details or well
N W abandonment details. You rnaii also anach additional pages if necestan.
CONSTRUCTION DETAILS OF W'ELIJSi BEING ABANDONED SUBMITTAL INSTRUCTIONS
.Ilydalr,well aV m,i 0'..a1 n•cnr.!•,r i7 d,w7.a',:a•. !•<v nrnlnprr nye'ahorr,v w.rravter iarpp4 -
welkONLYwithrheeomeawntroe canwhnr,trbreh.rm Ina_ For All Vkc%: Sirbnal this form within 10 dm.s of completion of well
ba.Nell 11)a:IP-C-1-25(ODDS) abaudoi nicm in the follottmg
Ditision of Water Resources,Infurmation Pnicessinc Unit.
1617 Mail Senice Center,Rakich. 9-1617
fill.Total Hell depth. 13 (p,) kr8h,NC 2769
lab.Fur Inirclios Wells: In addition to sending die forn to the address in Isla
2.25 abotr- a&' submit one :OPN of this farm within 1n dins of completion of well
(ic,Ritrelwdr diameter. __ irn.i abandonment to the followin!
Division or Water Resources,Undcrunutad Injection Conirul Program.
bd Water lento hrinw 1>triund wrfaer: (fret 1636 Mail Senice Tenter,Rakich,NC 27699-1636
like. For Water Suonh'& Inicctwin WeNe: fit addmim to sending the form to
be.outer ca.-,inc lcncth of Linn it is (ftl the addresstes( above. also suborn oak cop% of this form withia in da%s of
completion of well abandmmncnt to the coutut Health dcparnmcnl of the count)
it here aKindnmmcd
(of.Innrrcasin�'tubin�Icn;,Kh fit lJUliilU_ (R.)
611.Screen Icnilb(if kn,mni; Al[
(i l�. t ',\ Noith Carotnn Dcµ•i i ii ti two of Em iroiink vt;it d Nat uc�I Resowces-Dh gion of Water Resource, R%*W Angust 20 1 A