Wake_Well Abandonment_20240903 (19)

WELL ABANDONMENT RECORD For Irocncnl l w ONI Y
lliis form can be used for single or muhiple veils
1.(hell('ontrartnr Information: WELL ABANDONMENT DETAILS
Scott Hunt, Jr 7A.Number of wells being abandoned: 1
!!i.1•1 naaor Nance nor well owner pawits1h ahandlomag well on hallen propem i Fir mnloplr unle,lin# ur ,r x-ewer suppl, .ells O:VU rub the suer
.+di+rnr<n.Ni•d•a�rhniroi,-nr.r n,.nn.rFrour w.. a:rm
4561A
NC Well Commctor fcrtific•iltnn Nambcr
7b.Approximate%olumc of m tiler remaining in well(sIp 1ltltl 1
SAEDACCO FOR WATER SIIPPLl'U E1.1 S ON I I:
Caitganl Brame 7c.'I)pe of disinfectant used:
2.Well lromniietien Pefmit�:r r _. _sa., l �.•_ .-ri
Iasr idl rrpptaablr well prrmils rt.e.C•urwlt.S1nfe•I rasher In(e,nun,elt iJ A'm—,
7d.Amount of disinfectant u+(d:_
J.Well use(chcde well asd:
Water Supph Wcll: 7e.Sealing materials ailed(check:all that apply):
❑A-criculturil ❑tilunicilm[Public ® Neat Cement Grant F] Hentongc Cio&or.P!e kiis.'
❑(icothcrired Mcaurr_G('oolinp S ipph) ❑Resideraral W'aia Supph(snn¢Ici ❑ Sand Cement Grant ❑ Dr)(la%
❑hdastrial-l"omnrcmial ❑Rcsndentnal Water Supph isluiral) ❑(oncreic Grout ❑ Drill Cuttings
❑lrri •uun ❑ SpeCmin Gruel ❑Gra%el
Non-Water Supph%%ell: U Beutomte Slum U Other(explain under 7g)
®htonuonuc ❑Rao%ct%
Injectinn Well: 7f.For each material selected Amc,prnide amriant of materials used:
❑AqullURccharge ❑Grondx%alerRCniediatial Neat Cem. :941b ,Wtr:7gal. _ Sand Cem.:lb ,Wtr:gal.
❑Agmfer Sionige aid Recowen ❑Sahmn (Tamer
❑Agader lest ❑Sion n%aicr Drainage
❑Expennienial Icchnobg.% ❑SubstdetccC•orarol
Prm klc a brief description of the abandonment procedure:
❑Geolhernial(Closed Loop) OTocer
location was over drilled and pvc was removed from boring;
I!Cieothetmal(Heatin 'Cook Return) []Other( under ) --
tremie grout location from bottom to top
!.Uatc mall(.)ahaudiiirrA: 8-6-24
Via.Ih•11 lucalion:
Brownfield Road Landfill
Facibry lDM(iTappirabic) R.(crtilic;Winn:
2600 Brownfield Rd. Raleigh, NC 27610 8/7/2024
Ph,sical Addrem.C'm.aid Zip an•nof tz;Jtid W'<ll('murackrr r W'cIl(3wrcr DW
Wake By si}pullx rhos form, I hereby cern/Y 1AW the wrB(s)was(were/a6miduned in
COM) P e..l Ilk 11111-11 o No (PINT "vorhlate wrdr/J.4 XCAC 0N'.0100 or N' 0_s00 Well Ctmah'"won Skin(kirds
and tha a crept of this record Ave been pro%wkd to the well owner.
5k Latitede and lon8kmk in deRreeiiiiabenteslu. -ainds nr decimal degrers:
0fwell Ivid.uric L•ii.loug n milfic,cra) 9.Site diagram or•:idditinnal moll detail.:
You mat use Ilw back of thus page to µro%alc.iddinonal Well site details or%sell
II abatdomiicni dclailb. You min also attach xWitninial pages if necosan.
CONSTRUCTION DETAILS OF 1AEI-1AS1 BEING ABANDONED SUBMITTAL.INSTRUCTIONS
.Irrrxh wrl!aracrrrdr+nr n•corhs,�!sharable. F.r nnilnpk-rn�nnarr.v rrmi%.itar wlq•ir
arfdr O.V/.1'Mob rJk•acne:.+n•rrra o.m.Amralwnrnt cur srhmil core Ninrt. 10a. For All VV'ells: Submit thew form within 10 da%-s of completion of wx11
6:r. ell I I),,:
PZ-6 ah;indonnicm In the following
Di%Wou of Natrr Reno urm,Information Processing Unit,
61r.'total well depth: 40 lh) 1617 Hail Icr%ice(enter.Ralrich,%('276"-1617
Inb. Fur lnhctiva Wells: In adduwo to xtdinig floc form to the address III loa
abmc. AAi submh one corn of this furni %%ohm Ail"s of completion of%%ell
i.c.Birrcholc dianicter:2 kin.► abaodonuicul to[lie I'ollonow
Division of Water Rewurces,Untlergrsarod Injettiun Control Program.
(,d.Il atcr Icwel hi-him ground%urfuc c: 10 A) 1636 Mail Senicr Cater,Rakish.NU 27699-1636
Ilk. For hater Suaih A Initrtion Wells: In addition to sending the form to
6e.Outer casing,lc•n_thofhnomni: lft.l The addressi,!bl abu%e. also subitm one Cop% of this form %within ill dais of
completion of mdl abandonuncut to the cauniN heabh department of the court}
61'.Inner casin>r+tubin>;kn(Kh(if Iatnwn►: ($.1 %%here atnndoncd
6s.Screen length(if knomnI: (ft.)
Form GW-10 North(anima Depanmcm of lim ironnicn[a mi Nuurai Resoiuces-fli%iSlon of Waver RL-.orrca-s Re%red Augusl 201z