Jackson_Well Abandonment_20240624 (8)

WELL ABANDONMENT RECORD
This fomt can be used for single or mulliple wells
1.Well Contractor Info matioa W'F.I.I.ABANDONMENT DETAILS
Brian Ewing 7a.Number of wells bans;abandoned: 13
Well Couracum Name(or well owtter petsonalh abaardnutng wctl on hea lter propcm t F..r ro1r0014, olio l w .a, .*w-outer r+gy4i .ells 0%0 -iris elk, .Wac
-..--.erne n.Ni eh.+mlrwnoeo+r,tr+a+tor suhwrr.wtr F+r»t
4240-B
7It.Apprncimate rolame of patty-remaining in Arill I: (gal.)
NC Well Cargrncior Ccnifncalion Nnrrtkrcf
SAEDACCO FOR N ATER SUPPLY WELIN ONI.V:
Coutpany Name -c.'1'y,x of disirrfrrtarH u.ed:
2.Wdl Coast action Permit tl:,
fivalidplikvIllemell;wrmltr(i.e.C'+ . Shae.lariumv by&twn,rtr.,+jkw-ro -,1. %rnOYnt nl disinfiYtant ux•J:
J.µ'ell use(chn-1:well"W. ):
Water Supply Will: 7e.Sealing materiak uvd icherk alll that apple):
❑Agricultural ❑1�ltunctpalrPtthlic El New Ccmcnt(;exit I I Bcnlonitc Chips or Pellets
O(icothc nwil Mcannp)C4olia6Supply) ❑Rmidcrvtal Water Supph umLlci ❑ Sand Cemem Grout ❑ Un Clay
❑hdustnal('onu)Icrctal ❑Resndetticd Water Supph (shared) O Concrete Groul ❑ Drill Cuttings
Olrti Uon, ❑ Specialty Gtout ❑ Gra\CI
Non-Water Supply«'ell: U Benionite Slum I I Other(explain undo 7g)
❑hluuuornt ❑Recot cn_
Injection Well: 7f,For each material elected Alim c.finnidr animint of utaterials aged:
❑Aquifer Recharge OGrou dwater Rcuietitarton
❑Aquifer Storage aid Recoa en OSalimn Barrier
❑Aquifer TcM OSlommatcr Urauwgc -- ----.—
OExperimerual Technology OSubsndeiwe Control Pt m ide t brief de triptirin of the abandonment prucedurc:
OGcolhemtal(Closed Loop) OTmcef
O10imbermal(Hearin 'Cooliil Return) 190thct(c\ pin Under 7 i BENTONITE HYDRAULZCLY PUSHED IP-C-2-26 (EVENS)
r,. 4 V
4.113lateuvilWahandoncd: 4-21-24 1f N n L 9f1�
J
As.Well inatirn:
Rays Grocery ,( "
FxHgl-f_hrra:r Naura Facthh IDM(if atiplicabkl
x.l rrtilic.ui.uc
1674 E. Main St, Sylva, NC 28779 B Han n -M i n g 5/8/2024
Ph,sical 1a: - t+ .ik1%ir SiMpaiarcoMedifnedWellCow—i ..10wyCr DMt
Jackson R) simiti tg rhtc farm, 1 hereby r. r.n dw dw weUts)was(werei abanthined in
I'.n,cl Itk n,lammu No.(PIN) amorrhhat•e with 154 XCACOIC.0100 or 217 OM Well Conslrochan Shmdrirds
and that a crpi-of iris record hat been provided to the well owner.
Sill,I.:rtitude and hingitude in dt>;rre:rtialnutim1w. ctrndi or dtainal dt1frers:
of,%cll field one bu Mm_e t„ull+ my l 9.Site diagram or additional well details:
You flan the like back of this page!o pea ide additional µ+ell site details or well
N W abandonnteru details. You nas also atach additional pages if necasm-
CONSTRUICTION DETAILS OF W'EILSI BEING ABANDONED SUBM[TTAI.INSTRUCTIONS
.Htcule well crrrrrrrLclrv.rt m[r.r.!•.:+t.nwhahk- lief nn+lnplr ngrcfum r>r raua-Make snptrh
n etrx UlYLY wtirh riseirateewerhrrutwre aArrnbanrenr.iw can srbmit µrejemre Ilia. Fur All «ellgs: Suhmrl ilas fore within 10 days of completion of Nell
6a.Wee M#:IP-C-2-26 (EVENS) aNindomucnn to the follnttmst
Di%ision of Water Resuarcm.Information Prices-Ann Init.
12 (Q,)
1617 Mail Smice Center,Ra�h.NC 276M1-1617
66. lntal well depth:
10b.Fur IniexNon Wells: In addition to sending the fomt to the address inn Ilia
2.25 abmc.also strbtnil one copy of This fomt wubhn It)tans of completion of sell
bc.Rnrrholc diameter,_-_. lin.) abandonment to the lulimAing
Disisiva of Water Rewturcrs,Cader=ntuad Injection Control Prograw.
Ird.N attr k•rd btlml LiYrUnd W rt:Icc: _ (ft.I 1636'Nail tiro ice(enter,Rakigh,N('276'f9-1636
Inc. For Water Sunnis & loicctum Wells: bn addition io settling the form to
t.c.(hrrrca.in�lrnghii[I.nuant: i.ft.) ilk addresstesi abo%c. also submit one copy of this form wilhin ill days of
coinpletnm of ttdl abandrnuncnt to the cotuay heahh depannicni of(tie county
6f.Inntrcasin_tubinc Icneah.if hir.twn): (f,,)
nt 1xFc ahandnncd
fir.screen Icngih kit(.nor,n C t 11.)
Fern GW.an North C'atolsm Dcsinu>L+tl of Eur trunntcnl aid Natural kcsouncs Un+san of l4'atcr Re�ourcrs Rn ecd Aagusr 2n)I;