Wake_Well Abandonment_20240903 (8)

WELL ABANDONMENT RECORD For liaorrul Usc ONLY
This form can be used for single or mul(iple wells
1.IoNell('ontr•aetnr Information: WELL ARANDONMENT DETAILS
Scott Hunt, Jr 7a.Number of wells being abandoned: 1
'A,11( .IculotNAate lei%elluNraYperwrullyahardimng%ellunhxIrrpropcnsi f•v mnlnJdr mierrwm cr mm-wwrer svpph rrlb pal.) .... r, ..
r•ai•rrnc n•Nr.a''a+wArim.nr t,in.mr swlVntt rgir Firwi
4561A
7h.Apprwximate wilurne of w Ater remaining In wdksp (ga►M AcIt(mimKlnrCcntfrctl ton Nttt*cf
SAEDACCO FOR WATER SITPPIX WEI.I.S ONLY:
('anyun>Namc 7c.Ty for of divnfeclant used:
2.Wdl Coustructiun Permit 0.
List uN tµrptiauhh well perooniv rt.e.i'twerp.Mae.i anwme IrrtrtixnR etc.i if known A •, i �l, 1
"d. mdrnnt of disinQrtant used: J[P_
J.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): i.,'.,
❑Apncultural ❑MunicipaLPtibhc M Not('cmcnf Grmtt n Betaonite Chips or Pellets
❑(imthcrmal(Hcannal'ooling Supph l Mesodermal Waicr tiupph !single) ❑ Send(etneni Grout ❑ Dn Cla%
❑hidusinal:Comnrcicial ❑Rcsndcretal WaierStipph mharcd) ❑ConcrcicGrout ❑ DellCultings
❑lie 'lwu ❑Spersalty Grout ❑Gra%el
Non-Water Supph Well: ❑Beraontte Slum I other(explain under 7g)
QGMotittonng ❑Rnosrn
njectinn Well: 7L For each material weeded Anse.provide amount of materials M1ed:
❑AgnderRecharge ❑GroundwaterRenlediatnon Neat Cem.:941b ,Wtr:7gal. Sand Cem. :lb ,Wtr:gal.
❑Aquder Storage and Recroyety ❑Sahmh Hamer
❑Aquder West ❑Sbmnys(er Drainage _
❑Exprnmental Technology ❑Subsideticc control 7g,Pros ick a brief description of the:dwndonmeot pnocedun•:
1-16cothernral(Closed Loop) ❑Tracer
location was over drilled andvc was removed from borin
IlGeothernsal(Heann 'Coolie Relum) OOdier(cx am under' 1 — p g-
tremie grout location from bottom to top
4.Date weds)abandoned: 8-7-24
A&We"location:
Brownfield Road Landfill
8.Cenincation:
FacilirylOwacr Wse r, i�, in ��:.�t�t,i, Sri,. /
2600 Brownfield Rd. Raleigh, NC 27610 ! 8/7/2024
Ph.srcal Address.(rl%,aid Zip :tb<a'•ret o!' t..:f:d Well Comrxtai at W'ell 0%%mr Dale
Wake Ry .wjuitrig this 16irrn. I hereby cernJr dirt the w'eilfs)was(weret rdrmirk,ned at
l'awiq I`.iud kkWdaatnnt N•- TI%- act o ria/R'e with 15.4,VCACO2C.01000r:(_0.1(V Kilt Con..vmItanVarr[krr,1,
and char a rnpt of Mis record has bear pros ided to the well owner.
5b.Latitude and longitulk in dtgrcc%1minutruseconds nr decimal degr rs:
(if hell lcld,oar larking M sttifwwrnl 9.Site diagram or additional well details:
l ou m;h inn the back of this pt ge to pros ide addiltemial well Sec&tads or ssrll
N _ N abaidonntent details. You eta% alw attach idditiorcd pages if nt:crsvrn
(ONs I HI( ►ION DETAILS OF%loH.l tit BEING 4BANDONED SCBMITTAl.INSTRUCTIONS
.ii"ir welt i(12.1nr.1l:of rrcor.i-s'tl mwLa'4r. t.v rrtu:nl•i. :n,i ecu,c :i wdirr 6nppl.11
oowlkONLIr tooth rhe•.mmwLimmrrk ie)vcan whmtl,u:.". rr lira. For .All Wells: Subtrut Ihcs form within 30 days of Completion of well
6a.WeR IDO:
PZ-12 abandonm ms ent In the folltng
Disiskm of Water Resources,Information Proccol-ang I nit.
61r.Total well depth: 35
1617 MAiI Sersicc('cuter,Raleigh.NC 276"-1617
1f1.1
lob.Fur Infection Wells: lit addition to seilihim dye form to the address is I03
abosc. also subism odic copy of this form ssithm sn days of completion of well
6c.Ikinbolc diamcicr:2 lin.l abatdonuw•iu to Ilse following
Dhision of Water Resources,Under=nmed Injection Comtntl Program.
fool.Water ksrl ht•luw ground%it ifarr: 10 A) 1636 Mail%mice Center.Raleigh.N('276"-1636
loc. For Water Suonh & Inketkrn Wells: lit addipoo to sending the font to
6c.Outer casing Irnmghofl.nowni: the addressiesi abuse. also suboiii one cop% of this fomt within to dais of
:umpktwn of ssdl abandonment to tine couniN health depannieti of the count
(if.Innercasinr'tnbinL kn:,Kh(if l:nnwu>: (ft.) is herc ahandoned
6g.Semen Icn)hhh(i!'knownt:
Fomt GW-an Nonh C'amtim Ikpamirn of Ent ironnicd oral Nattrnal kcsauccs Dh ision of Water Raoim,,s Res red Atrgusr?)1 s