Wake_Well Abandonment_20240903 (4)

WELL ABANDONMENT RECORD For lowirtl Usc ONLY
This Gmir;an be used for single or multiple wells
1.Hell Cnntr•artnr Information: N'ELI.ABAYbONMENT DF.TAIIS
Scott Aunt, Jr 7A.-Nmmber of%tells being Abandoned: 1
Well CotarKsor Naar tot well owner penoleilh;lImni wung well an hurler propert% l'w maiapk dtlerllm W tKM-M at'r srg741 rMx 0%L1 with Ike wmr
r.M*rrnrrJrNt dhdtKhMMa'W.t.,n d,+aloud•wt, M1•rrr,
4561A
N<
7b.Appirnifinate rolurnc aP w;alvr rrmaining in iielgsl� (gal.j
SAEDACCO FOR WATER SCPPI 1 %%Ft LS ONI 1
Can>Otia+Name 7c.TNpr of disinfectant used: ;may':
2.Will Comatruction Permit w:r , Z024
fw dl,"4kdhk well p•rmjlx me r utnn.Mae.I eriame Inlet tian,etc.,,1 barn
74L Amount of dixinfiytant uxtd: lr
J.Well use(check w ell usel:
Water Suppl} Well; 7e.Sealing materials used Ichecl,all that apply):
❑ARricrohural ❑Municipll,Ribltc ® Neat Ccmcni(iron fl Rcraonirc C'hgn or I dicK
O(ieodierinal(IleanikWCoohng Supph,1 ❑RcstdcrYtal W'atcr Supph ismglc1 ❑ Sand C'erntem Grout ❑ Ur%Chat
❑Iudustrial.'CommerciA 011cmderttallb'aterSupph Ishared Ll (oncrete Grout ❑ DrillC'ulhngs
❑Mi trun ❑ Specialh Grout ❑GM el
Non-Water Snppk Well: ❑ Bervontte Slum I I Other(e%plam undet'g)
BNlunuonne 131keemrn
jectinn Well: X For each matriial selected ahmc.prxrnidc anumet of rrraterisls oKd:
❑AquICFRectum O(iromrdwalciRemedtation Neat Cem. :941b ,Wtr:7gal. Sand Cem.:lb ,Wtr:gal.
0Ayuiter Storage and Recmen ❑SAnuh flamer
OALpnfer lest OStonmNaacr Drainage
OEcprnntental Tcchnulogy OSubsidence Control T
>;.Prtiridr a brief description n(the ahan(loniiicet priicrdun:
06cothemal(Closed Loop) OTracer
tremie grout location from :bottom to top and cut casing
UGeothemral(Neann 'Coolin Return) OOther Icy am under 7 ) -- — ----
below surface
4.Date well%)abandoned: B-6-24
ta.1NcIl Intatitln:
Brownfield Road Landfill
F:kthn Ch.ncr N;urtc Facility row(if applicat+k)
R.Crnifkati(wr:
2600 Brownfield Rd. Raleigh, NC 27610 8/7/2024
Ph.steal Address.CND.and Zip b'x•re ate r:J.d Well('omraetm Or
Well Ch%rcr D4ie
Wake lh•ngrung/his Ibrm, l kem4,cernJl'that the well(s) ads award', shall lured lit
l a,u,n I'.,Kd kl nliic.nkm No Ml%'o act xwda r'c wA 1JA NCAC 02C.0100 ur 2(- NNV Rill Consiructt... �6trulurd,
and that o oWn of this record!wn heen prrn'rded to the well owner
Ith.Latitude and longitude in rk eex/minutrxlxcxxrndx or decimal digrers:
0f well fold one Lit-long n mara:iers) 9.Site diagram or additional well details:
1"Lit than tar five back of this page to prm ide addinotral well site details or well
N N' abii d emne a details. You nra% also jetach additional pages If necessart
CONSTRUCTION DETAILS OF R ELIASI BEING ABANDONED SCBMITT.AI.INSTRUCTIONS
.tflMh well,.oa,lnciaor rr.urd,�:l d,wltAhk I,w maieplcc dyecnrm or mm-loww arppfy -
»r'n.,ONLr»oh rhr war e,m,rrrkn,.n utidmA,trmenr v c.m whmd aura kmn. 10a. For All Wells: Subtrut then forni %cuhm ;o da%s of completion of well
6a.Wen IDO:P-2 abandonnicru to the following
Diiixion of N'ater RemiurcLs.Information Processing Unit.
6b.Taal st:n depth: 31
1617 MAN Ser-Oce Center,RAkigh.NC 27699-1617
Ift.l
lob.For lekytion Wells: In addilkm to senifing the funn to the address lit Ilia
abo c- also stdnnd one copy of this form withut a)dons of completion of i%ell
6r,lktrebole diameter:2 fin.) abardlontnciM lu the tollo%rmL
Di%ision of Water Resources,Underground Injection Contnil Priogram,
6d.W atcr keel hrinw moliml surfAcc: 10 A) 1636 Mail Scnicr Utimer,Raleixb.N('27699-1636
111c. For Water Suonli & Inicctitn Wtlll: In addinon to sending the form to
6c.Outer casing length iifknown): (ft.) the addtess(esi abme. also submit one copy of this form within t0 daNs of
completion of%cell ab:urdormicm to the cows% hcrhh e1cpartnicra of the:oust
w here ahindoocd
6f.Inner casin-0o bitiL length(if know n): (ft.
6L.Screen lent,Hh(if Lntrwn1; AI
f „,, r,',%-;�� North CirwhinDquitincraofEmnoencn:no NauralR.ewmes-Do%IsronofW'aurResoo¢es Re,scdAnenu-t-t: