Wake_Well Abandonment_20240903 (17)

WELL ABANDONMENT RECORD For laftnul Csc ONLY
this form can be used for single or multiple Avila
1.%Net1 Cnntracmr Informrltion: WELL ABAND(1NMENT DETAILS
Scott Hunt, Jr 7a.Number it("dlshchogabaadaued: 1
Well Coettactot!saoh .,%%ell ow irf perwruih ab3n&:ima j.%%oI oo boater proper i F-„r w,dnrh n,h'+n<or or anti-»sorer srpph wtfl. D.VL► rrrh Nk• .,ynr
c Nntrwcfkw ahumAAnMeW.)aN nur.=hx"f oar JFinn
4561A
NC Wctl Cotgmctnr Certification Nxn#mcr
7h.Approximate iolume of water remaining in%%rll(,. (RaM
SAEDACCO FOR II A'f F R St PP I I Il 1:1.I S ON I I`.
Conju m Name 7c.'1'y pc of disinfectant u%rd:
2.W dl Construction Permit N:
V•1"N d).t.(,"uh f."wef li•nml.+.re 11wan.Vase.I unaw-e lhgeimim etc.+if knawri -_
7d.Amrwnt of disinfcctanl owd:
3.Well ux(chttie well usc):
Witter Supph W01: 7e.Sealing material%used(chock all that apply):
❑Agr►uhural ❑Municipal Nublk W Ncat Ccmcnl(irtwt f! Hcrtromnc Chgrc or Pclicts
O(kothcm l(Ncanikgl'ooling Supph i ❑Rcaidcrrnal Water Supph isingict O Said Cemett Grout ❑ Dn Clay
❑IndminaUComnxrcial ❑Residential Water Supph Isharod! O Commie Groul ❑ Dnil Collings
Mitigation O Specialty Grout ❑ Girmel
Noe-Water Supph Well: ❑Bedonite Slum' U olber(c\plam urdLr 7g)
Nklomtonng ORcco%cn
lajtxtion Well: 7L For each matt•ri;d.erected altme,pro.ide anumat of materials m.td:
❑AgmferRecharge OGromd%ualerRenxdialton Neat Cem. :941b ,Wtr:7gal. Sand Cem. :lb ,Wtr:gal.
❑Aquifer Storage and Rttirn en OSalimn Darner
❑Agmfer lest 0S1onnK:ter Draltwge -
OExpennictual Icchtwlogy ❑Subsidence Control Prrt%idr s brief description of tlw•ahandonment prwcttilure:
OGeothernral(Closed Loopi ❑Tracer
location was over drilled and pvc was removed from boring;
OGeothemtal Meaun foolin Return) L)Ofhcr(explain under 7 )
tremie grout location from bottom to top
4.Date well(%)ahandntied: 8-5-24
5a.Well location:
Brownfield Road Landfill
F.,,:Pi. �;.• .�`..��� Facilih fDN(ifiipplicabk),
li.Ctftlflcitiom:
2600 Brownfield Rd. Raleigh, NC 27610 8/7/2024
PM sical Addresa.Cn).and Zip ar•n n!' txtd4as WCR('nntrtcMr or W'ctl(lwrcr DOW
Wake 11% xt)nunq therlfornt. 1 himby ce7nJy Nrtt Mbe well(cr was(were,ahcviduned in
Could% limed IdoW91cation No.(PIN) ruvronlinwe with 1JA. CAC 02C.0100 or Y- 0.'00 R elf Constrwchon Va"c tirds
and ibex a fxN!►'of this rrrord has been pi•rn tded io the weN owner.
5h.Latitude and longitutk•in&Vre.lminute.fseconds fir decimal degrees:
tit nett fold :or I:a b u i..uui;: i,: 9.Site diagram or additional well dttaii%:
You mac the the back of this page to pio%de addinorrat well site details or well
N W abatdounuta details. I'ou may also:ninth:&Mitmul pageb of necessan
CONSTRUMON DETAILS OF W'ELlatil BEING ABANDONED SUBMITTAL INSTRUCTIONS
.in.a Jr writ u.nsvncrknr mcurrhii{t u wl.atik. hue ndlipte infecnan(v ron-,+.filer wpph
xrit,UNLI".)IA the.sometworm(Ant ah.unknmi"i i.m eau whwa core ka+n Ma. For All Wei.: Submit this tort u-ithtn -,O days of completion of well
6a.W'ell lDd•
PZ-6 ;iNmdonmcni to the follnuiRg
Uh ision of W%ter Rewmrcc..Information Proctssing Unit.
1617 Mail Smiee('enter. M 2 6941-1617
61).Total soil depth: 35 (ft.l
lilt).For Initclion Wdls-. lit auk two to biding the form to ilk address ut lu;l
re.RortMdrdiaaxHer.2 (in.) abo%c- atsu submit one copy of this form uithni tit days of completion of%tell
abandonnienu to the follouutk
Di.ision of Water Resources,l;ndertround Injection Coatnrl Program.
fid.Water keel hdow Xvirand wrfacc: 10 (ft.) 1636 Mail Senior(•eater,Raleigh.NC 276"-1636
10c. For Water Suath & Inicetion Well: In addui(wm to wMing the form to
6c.Outer casing length Iifkaowm): OIL) the addreas(ebl abote. also submit one cop% of this form %sitlun %n days of
completion of%%cil abandonnxnt to the coma% Ixakh depanmrt of the county
%lxre abandoned
6f.Inner casing,,'tuhing knlrth(if known): (ft.l
6g.Scm-n Irngth(if known): (ft.)
ForiuGW-3o Nonh C'amhm Dcpartnrn of En+irouniem:oil N:uural Re\ iMCS-Dhsst06of%'alCf R,-W uc%•s Rc%wed Aupust 201%