Wake_Well Abandonment_20240903 (5)

WELL ABANDONMENT RECORD ForlwmilrwONIY
This form can be used for single or nrolliple%ells
1.Wee('nutractrir Information: WELL ABANDONMENT DET All
Scott Hunt, Jr 71L Number of ue113 being abanduned: 1
Well Conuaetor Name tot%ell oanrr penotulh Amftkm,,y%cH tit,fir,it: prtyxm r t'e' mnfuph' oth•tluur or rMm-MAre, svpfA .ells rr%1) -rrh Mit• uww
—n,rno ii,v,,lhowhomrrt.min t,or rmMtg.wee(,rm
4561A
NC Well Contmdnr Centlficatioa Nombcr
7b.Appmximatr volume of aahr remaining io neBlsl� IRal.l
SAEDACCO FOR N'ATF.R Sl'PPLY M FL1 ti ONLY:
CA Name
�1 ?c.TN tic of disinfectant used:
2.Wdl Cow. Permit N , , L�' J 2024
Ilsr ill aWitvllk well permits fr.e.(`t nn.S7trle.l aname lntetim,n.el iJAmro -d.Amount of diNnfMAnt Melt:
J.%4dl use(cheek n ell nw. 1-
7e•Stalin materials used(check all that apply):
Iv1.♦Pater Supfd?Well; A PP. -
❑Apriculntral ❑Munncnpalpinblic ® NcalCcmcmGrout n Be+rffnift Chips orPelkts
❑Geothermal IHcangGK'oolinc I-44VIi l ❑Rcsidcttnal\Yatcr Supph nsingici ❑ Sand C'enietrt Groat ❑ Dr%Cb%
❑Irdusinal:Commercial ❑Rnidettnal Amcr Snrpph i%liarcd) ❑Concrete Grout ❑ Drill Cullings
❑Im 'tton ❑ Spectalh Grout ❑Gra%el
Non-WaterSupph Well: IJ BetltoniteSlum I Other(e\plam under 7g)
ifl Munnonne ❑Ram en
Injection Well: X For each matreial selected aho%c,linnide aiwiivnt dif uaitteriala•std:
❑AqudrrRecharge 06rounthiaterRennednation Neat Cem.:941b ,Wtr:7gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Radn cn ❑Salliuh Hamer
❑Aquder test ❑Stonm%atetDrAlnaec —
❑Expenntental lechnolop ❑SnbsdelreC'ontrol
?>;.Pnt%ide A brief description of the aibandlonnnrat pnknlnm:
❑Creod mrdl(Closed Loop I_ITfacer
location was over drilled and pvc was removed from boring;
OGotg6ermal(Heating-tooling Reninu I 10thet iexplainunder, ) --
tremie grout location from bottom to top
4.Dart•%elks)abandoned: 8-7-24
�A.\\ell Inc Alion:
Brownfield Road Landfill
i.•:rr. ,r,.�,r•..��, Fxilw%Ifhr ri7 applicalrkl R•Cerlificstias1:
2600 Brownfield Rd. Raleigh, NC 27610 I ` / 8/7/2024
Ph.srial Address.Cm.Ord Zip �giR%neo-.4ot�. Well t'trnrrecior in Well(h%rwr Date
Wake Ry aXweig)his Jform, 1 hereby cerhly that the weH(sf was rnrere,aNnitluned ill
t1�:ir;n I'gal ld.'rldaanlr)1t No IPISI arconhrnt'e with/3A.4 AC 021C.0100 or X 02M Rerll Cenrtrucrtnn.Vari mix
and that a copy of this record hen been prnn•lded to the well ou ner.
Sb.Latitude and longitude in degrirslminun s:seconds err decimal degrccs:
tit cell fcW.one Ut kmg n wliscwtt) 9.Site diagram or addde"*4 detaik:
You nine% rcc the balk of this page to pros ide additional uell site details or%ell
N _ :nbandonntert details. You run also attach addnitrnial p%13s if nKtitasan
CONSTRIATION DETAILS OF\\El-IASI BEING AHAS DON :1) SUBMITTAL INSTRUCTIONS
.i(fik it melt ion0ni,1mr1 rru,rd-e 11 a, 1.1110jl. uy.tb•,v•v rr•n-ester wtgttr
erfsONLI rich the nrAiretionfri ergon i mEtm ahnnitow row". l0a, For All Well%: Submu thet f6mi utthrn 0 da%s of connplclton of %cell
ba Well IDf
PZ-7 abmdonnieni to the following
Dh Wog of Wmer Resources,Information Processing l nit.
1617 Mail Smiee Crnter,Raleigh.NC 2 7699-1 6 1 7
6b.Tuttil well depth: 95 fh.l
lob.For IsMclion Wells. In addition to sending floe fornn to the address at lua
abo%c. alw sebum Dort copy of this fornn%snhm its"s of completion of%ell
bc.Fern ludo diameter:2 lin.l abandonment to lire following
Dhision of Hater Rc«rurrds,l:nderxtvwud Injection Coittnil Program.
d,d.\\atrr Ic%d hrinw ground surfaer: 10 (ft.) 1634t Mail Smite Center,Raleigh,N('276"-1636
ten I(1c. For Water Suotih & Inkrction Wells: In addition to xnding tlw form to
6e.Outer caain
g length(if tanwn). lft l the address(esi abu%e. also submit one cop% of ihu fomt wilhm 'n Class of
completion oh well thandoninent to the covet% health d cpsnnlent o1 the:oun1N
(of.Innrrcasing'tabing entah iif I:nn%n): Ift.l where abeindorn d
6g.Screen Irn(Hh(if knonnis (f1.)
Form GW-ii) Nonh U;irohm MpanorcrA of En%irouniera and Narwml Itesommes-Dh ision of Water Rcsoarccs Retied Aopist 1)1 t