Jackson_Well Abandonment_20240624 (7)

WELL ABANDONMENT RECORD For!roents,Use ONLY
This form can be used for single or multiple Neils
I.Well('ann•actor Information: WELL.ABANDONMENT DETAILS
Brian Ewing 7a.Number of wells being abandoned: 13
Well Contractor Nana:tot well emir personal])abandoning well on hu er prapen)I F.f mulnplr 011rtttur .f .ru,-o<rter sw1YJ. ..lh (1st 1 .rd, Nk .wnr
r.,,t.inr<a.,w.rl•an<hOMerir.Low trot rwhm,r• t.M1.rm
4240-B
NC Well Contractor CettiftcalmnNumber 7h.Appnisimate tolutne of water remaining in Welk'.: tgal.)
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Wdl CMstntetiou P(7utk N:, , WI0100715
Liar ail applicable well permits tie.('uwar,.Asir,I Jnwtce 1%.4,0101e,ch.,.l k,ror" 7d.:\m(wlif of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing material.used(cheek all that apply :
❑Agncuhurat ❑kluniclpal/Pubhc CI Not Cement Grout 11 Bctntonite Chips or Pellets
Geothermal(HcatingK•ooling Supply, ❑Resideiatal Water Supply(singlet ❑ Sand Center Grout ❑ Dry CLt}
❑IndustriallComntcrsral ClRestdenan:d Water Supply rshared) ❑ Concrete Grout 0 Dull Cuttings
❑Img:ttion 0 Specialty Grout 0 Cita%el
Non-Water Supple Well: f1 Benttonite Slum I 1 Other(e\plam under 7g)
❑NIonuonne ❑Recoyrn
Injection Wen: 7f,For each material st'Iected shone,pn►side am.. I materials used:
❑Aqua er Recharge ❑GroundwJIer keniedi:mon
❑Agmfer Storage and Recovery ❑Sall its Darner
❑Aquifer'Pest OStommater Drainage -�
❑Experimental Iechnotoen ❑Subsidence Control -g.Pt .'.t<in.i brie!de.criistton of the abandonment procrdurr:
OGeothermal(Closed Loopt ❑Tracer
BENTONITE HYDRAOLICLY PUSHED IP-A-2-26 (EVENS)
OGeothemtal(Heating•'C'ooling Return) I➢Othcrtexplain under 7gf —
4.Date otitis)abandoned: 4-18-24 JUN 202A
� 4 Y
5.a.Welt location:
k4w P -434•410‘`74 URik
Rays Grocery aAO- .JQr
Faeilii)"Otanet Waits- Facility IDN(if applicable?
X.t rr lilt:nLuc
1674 E. Main St, Sylva, NC 28779 _Brian Ewing 5/8/2024
Physical Address.CH, Signature of Canned Well Contractor :.a:d Owu¢r Dote
Jackson BE wrung they Jonu, 1 hereby err*that ike wellts) was/werei afiandumd rn
Coast) l'✓ttct lde.difwalan.Nu 11'I\. accordance with 15A NCAC O:C'.0100 or 2C.0200 Well Construction Standards
and that a cope of this record has been provided to the well owner.
5h.Latitude and kingiturk in mkgrccslminutreseciindy or decimal degrees:
of wen 1"L1,1 one 6u.Mau_...n1l.c>Lrt r 9.Site diagram or additional wel details
You niat toe the back of this page to pre%ide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
( 110\ 1)E:I ><II (If 11 El I•;.i BEING ABANDONED SUBMTTTAI.INSTRUCTIONS
welts°NLY.al.'be..unwrt.s,.,rnenw,.i,wnh,.w:.ral.lur can submit(me jam Ina. For All Welts: Subintl the% leant within iO days of completion of well
IP-A-2 26 (EVENS) abandonment to the following
,..�.‘\t41 11)=
Division of ater Resources,Information Processing l sit.
1617 Mail Sersice Cater,Raleigh.NC 2 7699-16 1 7
oh. total well depth: 12 aft.)
lob.For In kenos Weill: In addition to sending die form to the address tlt drat
on.R.tnladr diameter 2.25 fin.) abuse. also subunit one copy of this form within ;O days of completion of well
abandonment to the lollossmg:
Des ision of Water Resources,Codergrirund Injection Comm'Program.
644 Water level helots ground surface: (h•) 1636 Mail Service Center.Raleigh.NC 27699-1636
Inc.For Water Satn)ly & lnk'CtNNI Wells: In addition to sending the font to
6e.Utter casing Icnanh(if know nl: (ft) the anddress(est abuse. also subunit one cops of this form within to days of
completion of well abandonment to the counts health department of the count)
where abandoned
t.(. linter casinionthint!len:,'th cif limos i: (ft.)
6g.Screen length!it Lnow n t: (ft.)
Forst GW-3o Nonh Carolina Departure!!of Ens i inmcn aid Natural Resources-Dis tsnon of Water Rottmrse Re.tied Augurs 201 s