Onslow_Well Abandonment_20240624

WELL
ABANDONNIENT- C O. FuTImml.UsoONLY:
This foini cad tie.tlsed for single er multiply vfielis
1.WcU Cootractur1oformatlow )YrLL.ARANDONMENT DF:TAtr!S
Stefan Smith 7a.Number ofw1h.bein);ab ndanlds i
Wat OminklorNau7 6rucifoivndiictBana4.nli5•nddd htg well oa 1&16cr prupC..4) For rutdnple tl1(erumv at; Peul-YIY(�eY 31rppxf wells OVLF wttb the swxa
_ - rMiCfirPCn(Nd�RI,NPdflnAltRdr,,YYJPP Ly81 S71(NJt!(OYfEfPJRJI,
3576A �,•
NC NIM)Cont caorCvitlfuition Noirbcr
7b.Appn)sinrate vnlniite of*atcr re" in vi cll(s)i (ylaL)
SAEDACCO FOR NVATER SUPPIN NITUS ON'I.Y:_
Can>pan}.Name
7cTypero.Edisipfi�etantuscd;.% calcium hypchlorite
a
2:Nvitl Consftuct€on Permit g:',
Iturdlill pk- ole 004m.,gt,Ne.l'urjumv.briectium"Y1 Ottawa 3' oz
lid Amount of disiufectaut ukd..
3.Wdl ustr(ehcck-well pre}
Water Sirppl4'`Yell: Vic.soling'iitate¢ittls ttsctl(ehacl;all tent ripply):
t7ASm-itlhtml MMmkipallt'ttblic. 61 Mai Ccaicot.Ginut, 0-Nnionitt Chips of Nliets
Wsmilmovat(HcatineCooling Supply) tMesideatittl Water Stvpply(?nS191 >a Sim CerrterU Grout 17 Dry CLy
❑hxhisiriallComntcmial I]RWdentiat.%V:iter.Supply(sharcd) p G©nciete_Gtout ❑DrillCltttinp$
mlrti tiau I7 SPeciulty Grout ❑Grsrgl
Nee AYatcr Suppir%YCi, D,Hentonite wrw 0'Other(explain under 7g).
UMotiitodug ORezotety
rujoetion Nvcu: W.For,each utaterLd selected above,pimide atuountnf►uateriarsUSA-
OAgeifer[tecbarge,. itetnediotion Neat Cem.:1881b ,Wtr.:15gal. Sand Cem.:lb ,Wtk:gdl.
I7r9gtufec Siotagewxi ii&bVt:.ty oSuliidty 136rijer
t]AiluiR+761t Mlonnt vaterUminnge
L7E etetitettlal Tecbito[o v i7Sulasidellcr:,C6rnlml Fimide a.brief d6cription of the abd)sdonment pn►6edure:
Meodwrnmt(Closed Loopy OTracer
Grout.abandoned•via treme
®Geotheintal(HeiYtin.W'CooliuARetum} ®Otia:r-(e� laiuut►di:r7 )
d.°Datcvtidl(s)abandonetF: 5/16/29 �• C__(1..:-
a well lticJiiioen: 9 24
Gregory Shepard lf�ia:T.k kt el P,^v,,amQ`
8:Ctertiltrstioir:
Facildj•IUYviYcrNnitic Facility°ll]l/(1fupplicatitci
217 Diane Drive; Jacksonville 28540 wtL��j 5/27/2024
z"Imed i'hvsical Addres,City.and Zip S•v -Inzc Noll Cquirictor or,tVetl 0 wr Dato
J�,sig"Irw-this form, 1 lrerrby Ce 0y_:that Ow wellf,5) was"(here)ghandotied in
County Nrcel ldcmipfc tlJYit No.iPJN) ficxunlatice ivith'l i.i;1 C'r1C 0 C;111(FD.ur 2C.o2oo me1l�cJirn7ratctlurr 5(rrhikrids
and drat q`cnP3 o}7lrisrcCitrcllxrs beery provic etlla llte.Yi ell otviter
Sb.6.MifAdc And-longitude in ctegnsesfniintiteSlsecoritLs"oi•cleciutaB destrc'm
{irn•en fvl ono tarJteu tti.,rmcirt>o? 9.Site diagram or additional well details:
You tuiy use tl e,liacl:�ef ti►is page to Pro�•ide sddifionat 1!site.d ils.orn�ll
34.767529 77'.492032 . . 4V,: :atiaudomnetddetails I'outuv}aLsoat�ac�taclititiotrtlpab siftsecx sat}(
CONSTRUCTION DETAILS OF WFLL(SI RFIN(:AR,'1NhONEIb
suRnm�TAi. TRncTrovs
.lrtruli v;rll twnrtnJclirJJr-PicvrcllsY ai',riblluble .!'ur'Jnidntile bg�cfuie tir run-u�i:ar.4i,}pli� �
wetLaOVLl YiiOJL`ti sr11JnP1rilcslrrxllJiruL�uuFrJ,v.Jeru_irJucnra�yibmitcurefunn 10a:,Frir All Wclic• Submit IliLs f6tin-siit6in 30 dxvs pf e6wpletinn"of tvrll
abaitidoutti¢nt to the folloivin�
. Div€Sion of��'atcr Rc�tturri�,tnformntiod Ptvccscirtg.Cnit,
6b.-T®tat ivelt depth: Unknown tag-2 9�R.) f�iT NEWSciiiee iCintcr;Itale€ylti,NC 27G9'1-IGl7
trio:Tor Ili Im ion Wells: In addition to sending the fotni to the adiltm In 103
6c.E3orohole didttnMer:2 abaw,atso submit ottG"topy of ildis foiYu tvitliiit 3d dityS,of completion of-yell
(iu.} abandoitmial to thefnllo�viug: 1
Ucl,Water RcF'ci ha tote DIVIstop of Water Resourir�,iiitdergr•ounil hi jectto"Coatrvl Program,
proaod SurfacCC 14 {ft.) i63f►11 A I Scriiec Center,Raleigh,NC.27G99-1636
6c.©utcr casing length(iff lane u): {ft) 10c,Tor Water Sdmtily.0 inlectiivnl lYeliv; In addition to sendiu3'the foam to
the-addresses) above. also subatit ooe copy of this form within,30 days of
coulptetion of udl abmdotunent to the oouJ;iy health'deptirtn1cut of the County
6f.[niter.casinWtubinp Ien;$4(if(atone): (ft.)
vvhcm ibandoncd,
617 Scr6m length(if knout n):
FormM-30 NaoliCamtimMparlmemoTEnviv mxetatYd Mimi Resotacs-DivislanofWaterRtsmucs Revised Ansosa20t3