Wake_Well Abandonment_20240903 (18)

WELL ABANDONMENT RECORD Rif tntental Use ONLY
This form can be used for single or mix iplr imcllp
1.Well Coutrartrir Information: WELL ABANDONMENT DFTAII S
Scott Hunt, Jr 7a.Number of walls being abandoned: 1
WellCorttaclor N.:m,i,I Lull usutr pciWIL11h. :duid(unng(.e0 mi hither properry 1 F­ mldoph• uor(iwm or rrwi-wafer .w/!rat wrN+ ONLY with Or aw
(v)µrfrt(CENNI 17�aIrl•inhrtt.IrtM(0/Wholif me farm
4561A
NC Well Number7b.Approtimatc s ulumc of cater rrmair inf in
CotsmcynrCertifirninn
SAEDACCO F O R%A'I F R S 1`PP I.1 W F 1.1 S l 1 1:
Conpam Mani[ - .
?c.'1'ypc of disinkctant used:
2.11 ell(Um+truce ism Permit M:
; I X, I� I I01i Side.1 ortuw a hgrri m,rk.I if warm ?d. %mount of disinftNtanl uxd: T P'^}m7
J.Well use(check.Hell use):
Water Supph Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal Public 0 Nrnl Ccmenl Grow t l Rcraori tc ChpS o peklta
❑(kcithcrmal McawkwCooling Supply) ❑Rcstdeonal Water titgtph i-ani ❑ Sand Cement Grout ❑ on(la'.
❑I dustnaLl'omnicrcmal ❑Rcsidcntial Water Supph tsh(red) ❑Concrete Grout ❑ Dnll Cuttings
❑Ifn •toll ❑ Specialty Grout ❑Gramel
Non-Water Supph Well: Ll Bentorute Slum CJ Other(explain under 7gI
Q➢hlotnlonuu ❑Rccoicn
Injection Well: 7f.Foreach material w-lccted Alici prude areinrnl lif materialstned:
❑Aquifer Recharge ❑Gmutdu;uerRemedurron Neat Cem.:941b ,Wtr:7gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Ii en ❑Saluun Hamcr
❑Aquifer Pest ❑Slonmmalcr Drnrwge —
❑Experimental I Lchnwlop [Subsidence Control 7g Prin ide,a brief descriptirin❑f the a handinuncnt procedure.
OGeothemial(Closed Impi ❑Tracer
location was over drilled and pvc was removed from boring
❑Geother mal(lieatm 'Coolin Return) f 10thi ic\p4am uni'kt -- -
tremie grout location from bottom to top
A.Date l elllm abandoned: 8-5-24
5a.Well location:
Brownfield Road Landfill
•.CeelMit a11N:
Fxilm�Cl.(ncrNamc Fxilam IDw(ifaQplicabk)
2600 Brownfield Rd. Raleigh, NC 27610 �/'(/ 8/7/2024
ds tMMM
Phi sical Address.Cmi aid Zip i :FFFf d W'e11 t'amector ra w'cll OnMi Daw
Wake 1h .vigninq thew Jforrn, l ht:ir6y cernA,Mai the welli was rweret ahwichnied ut
Coutni Paled Idemufle tba No.(PIM (hex onl(ii with It3A 1sCAC 02C.0100 ur:C U_'00 R'ell Conyowetr(rn.Van(kirtA
(md than a cii oJtria reword bw been prrmided to the well(inner
5h.Latitude and longitude in lictir s/mirmtes/secnnds or decimal degrees:
!il ne)t fill ore Lo W+q_n+unlcaif i 9.Site diagram or additional well details:
You nta%use the back of this page to prom de addiucawl uell site details or cell
N W abandonment dewtls. You rtwm also:mia_li ankh ial pages if nets
CONSTRUI TION DETAILS OF WELL(S)BEING ABANDONED SUBMFTTAL[Nc_T_RUCTIONS
.trunk wvP curtr Mdowr trcurdiv(7 Ln uldhk. F'w•mufrrpk thoectiew.r mm-w ppfrain su
writrl/.11.f wuh rhr..,i(M(uicnewrwnal m(klmnent.iwcun+rFmli.wrr,t rnr loa. For .All Wcn.: Submit this form within 1;0 dais of completion of hell
62.Well IDp:
MW-P9 abatdonnlem to the follmcmg
Disisian of Water Rewrili Information Processing limit.
1617 Mail Smice Center.Raleigh."1 27611617
6b.Total cell depth: 37 fh.l
Inb. Fur Initrtivo Wells: In addilkiii to seui ig the form to the address in Iba
oc,R lnholc diarneler;2 lin.n ahoic.alw submit uric copy of this form umthin 30 days of cumpletion of cell
abandonment to the lollouine
Ditision of Water Resources,Underi unod Injection(ontrul Program.
od.1\titer kt(i below gnnand wrfan: 10 olo 1636 Mail timice('enter.Rykigb.NC 27699-1636
Itc. For Water Sunup & InieYtilum Wells: In addition to sending the fort to
oc.Outer casing length lif known): 0110 the addressees) abo(e. also submit onii: copy of this form within 7n da,s of
completion of%Nell abandoilaxon to the county health department of the count
rmlxrc atnndnncd
6L loner casinWtubing length Of known): Ift.)
6t.Soren length(if known): (it)
Fom GW-ai i Nonh Camttm Dcpiamo of En.ironnicn aid N:uural Rcsoini cs Dis ision of Water Rsownrs Rcs iced August P)1 i