Jackson_Well Abandonment_20240624 (6)

WELL ABANDONMENT RECORD Fottrowmil Us:ONLY
This font can he used for sino;k or nttrlliple Wells
I_Well Unntractnr Inftrrmatioc W'F.LL ABANDONMENT DETAILS
Brian Ewing 7a.Number of will.bctng abandoned: 13
Well Coteracrot Nang rot wellownc'r peminall)abatdotnng well an hi9,her properly i F„r malapfr mtviti„a ,Y ww-Mare►' itgrA relk 0%11 -oh the +awe
r'•Nleryiiy fi,M•rl,anhmmtn t.IVIM(Yar 1'uhm)(,vic Boost
4240—B
NC Well CommdarCci ificsinn Natiibcr 'h-Apprnnimate iolutne of water remaining in Viell(si: (RAL►
SAEDACCO
FOR WATER 5IlPPLI'W ELLS ONI-Y:
Corryiatq Nam -t.Ty pt of tYfiaIK- 'mud:
L Wtil C"Antctiaa Penuit C, , WI0100715
l�rr,di„ppfkaAJr oriel/pererrlr n.e.Custarl.,N'ANe.J arj n e lnte,iron,e1r. i)6tmre _d. used:
3.Well use(check Viet]aseh
Water Supply Well: 7e.Sealleg materials used Icheck all that appl}):
❑,Aer calturd ❑htuniupahPublic ❑ Neat Cemcut Gniot n Bedonitc Chips or Pclicts
D(icothemt:il(Heating.'C'oolitie supph i ❑Residerttal Water Supph t.in les ❑ Said Cement Groin ❑ Dn Clay
Dlydustrul:Comntcrcial ❑Rmdential Water SuMh isharcid) ❑ Commie Grout ❑ Drill Clulinp
❑irn •tioii ❑ Specialty Grout ❑ Gratel
Nam-Water Supply Well: I Bedonite Slun}' I l Other(eNplain ulyder lit)
❑ivlontfonns ❑Rccoten
Injection Well: 7f.For cacti material sleeted ahnic,prvrtiric•amount of materials uwtd:
❑Agmter Recharge ❑GroundWaner Reutedt niott
❑Aquifer Storage and Recocen ❑Saluuh flamer
❑Aquifer Test ❑Slommatcr Drainage --
❑ENpentrictual Technolon ❑Sitbsidclocc C'otatol g,Pent ide a brief description of tihe abandirnnient prncedun•:
OGeothential(Closed Loops UTracer
OGeothemn tlNratin e101i1[ Return) 10(Mrcrle\ ainurider7 1 BENTONITE HYDRAULICLY PUSHED IP-C-2-26 (EVENS)
,. ._ _
L.
l_Date welloo ahandnncd: 4-21-24
.JVA � c� LUL'I
54.%%ell Itnation: UM
Rays Grocery
FxiliglOarrerNamc Ferule iDM(if appliabkr R.Crnificani 1i;
1674 E. Main St, Sylva, NC 28779 _Brian Ewing 5/8/2024
Ph,skal 4ddrcss.CIh..aM1 r Stgrrenrc of('reified Well(bntracior t: ..*.It O%uer DOre
Jackson Rt .vigiurig An jrrrm, I hereby cergA-that Bee welf(s) was(werei abaudoned fit
Coam4 I amd Id.lnifLLaiNni N,, WIN i acronkince With 1.1.4 VCAC 0:C.01Of)or.Y7 02()0 Il'e11 Ccvishrtc7tott Sttmdurcl.
turd drat a cape of this record htu been provided to the well owner.
tb.Latitude and InnRitark in dcRrccs/mirwtcalaccrrndx or decimal degrtta: �
(if,cclf field otic Lit long K,ulticieif r 9.Site diagram or additional well derAn
s:
You alai lose file back of this page to prcn de addiueird Well site derails or well
N W abair)otintent details. You nun also aitach xMitwtial pales if necessan
CONSTRtl(-nON DETAILS OF W'ELUS1 BEING ABANDONED SURMITTAIL INSTRUCTIONS
.(f"h a aiwhd,:e. )-,.v mutfiple ugecb+ur,u,YV)M 01" •n;g,ii
welk ONLY uuh eke moor t mirsrrwn aliarnkwr ent.iw can gd(ona ore twm Ina. For All W'rYs: Suhmtt [fits form within 30 dn%.s of completion of well
La.Wail Ill=:IP-C-2-26 (EVENS) ahaiidoirnicni in the folkncmg
Diiision of W'atrr Resirtrrces,Information Perim sling fait,
(rb.Total well depnh: 12 h.)
1617 Mail Senior Crater,Raleigh,NC 27699-1617
i
10b.For talcction Wells: In addition to sending the form to the address in Wa
2.25 aline. absoi srrbnu copy of one co of this fonn Wnitiu o days of completion of Well
(K.Brtn•lu,k m•diaeter;_ tin'► ahatdonntenn Ia the tiillotcutg:
DolioWou of Water Resources,I ndcovrinind Inwction(ontnil Pnit!ram,
641.Water iet rl bchrw gtirund.lerface: (ft-) 1636 Mail%mice("cntcr.Raleigh.NC 276"4636
Irk.For Water Suwtlt & Injection Wells: in addio4m to xwriding ilte Rion to
lie.Outer casinglen^thiifknowno: OL) the address(esi aboxe. also submif om cop% of this form Within ill dais of
completion of iidl abandon icni to the couret heahh departmera of the cortm
ulurc att:tndnricd
(of.inner casin�'tnbin�Ien_Kh/il'Lnnw n,. (ft.)
61.Soma length(it 6n4n n i;
Fornt GW-its North C'arohrn Departaletr of En%iroraeerr and Natural Rewmaces-Die isson of Water Resoufaxs Rc.cad Ampia 14)1 t