Wake_Well Abandonment_20240903 (10)

WELL ABANDONMENT RECORD I'm I AmlUxONLY
This form can be used for single or mttiliple%ells
I.Well Cnntracmr Information: WELL ABANDONMENT DETAII S
Scott Bunt, Jr 7aa Number of wt•Ils being abandoned. 1
Well Contractor Namne nor well uwnrr perwimlly ahan&,ning well an htv lien proprm I F,N mulaplr oilechrw rW Wm-rarer supph cells ONU -A rhr +twee
r.NI•frryr!lie Ni,la�)ak(r 41lJl,'In.I�rn lrUf tNh/lnf rNlr h,rnl
4561A
NC Well CotttmeMr Ccnifiatti(tn Nnnber
'b. Approtinaa nulumcuf water rrmainingin%clN�l� Igal.1
SAEDACCO FOR 11 A I FR SI'PPI.t'W'FLI.S ONLY:
Cotrpen>Name -c. I v lw of dl.mkctant urrd: FPP
2.Well Canatntction Perak
l ry all rgrlleavhk well permav u.e.(ulan.Smw.1 anwKe Lryeownt etc.r if Arorfr
7d.:rmrwnt of disinfietanl uxYl:
J.Well use(cbc&-wcfl use)-
Water Supply Well; 7e.Sealing materials used(check all that apply):
❑Agnncnhunl ❑hlttnncipal.,Pubinc ® Nett Ccmcni Groot n Bcntonac Chas or Pellets
❑(icothcrmil iHcang4'C00lin9 Sttpph I ❑Rcmdcmal Water Supph nstngicl ❑ Sand Cements Grout ❑ Dn Clay
❑lidusinal:Comnterctal ❑Residential Water Strpph ishared) ❑Concrete Grout ❑ Dnli Cullinga
❑Im •tnon ❑ Spernalh Grout ❑Gratel
Non-Water Supph 11 cu: ❑ Bedonite Slum Ll Other ee\plai n under'gl
EMomionng ❑RCCO%cn
Injection Well: 7f.For each material±tdeeted aboic.proOde amomat of materials med:
❑AquderRecharge 06routdwaterRennednation Neat Cem.:941b ,Wtr:7gal. _ Sand Cem.:lb ,wtr:gal.
❑Aquifer Storage and Recom en ❑Salnlnnl\ Itar[trr
El Aquifer lest ❑Stontmaier Draintaec
❑expenmen ial Teclmolog. ❑Subsidence Control
7g.Pnn irlr a brut description of the abannklnmcnt pnKrtlun:
❑Geothemul(Closed Loops ❑Tracef
location was over drilled and pvc was removed from
❑Cneotbemul Mea6n 'Conlin Return) 00thet 4explain under' 1 — - -- — --
boring; tremie grout location from bottom to top
4.blare widlis)abandoned: 8-7-24
Sao Wer hwAtion:
Brownfield Road Landfill
Fxilnh Yia to Nam R.Cenifkalion:
c I ,.�I�. Ile ��C i;.i.L J I• /
2600 Brownfield Rd. Raleigh, NC 27610 / 8/7/2024
Phvskal Ad&c�s.Cnt.nd Zip o!' rK�Wd WeR('murxlar nr W'c1l0wner Dane
Wake By-ngwtng this form. I hereby,cerwfv that the well(s! was/sere, fdumitknied ur
('rwWi I jt.ci Idemtfaatnm No IN%I rurordawce with 114 AT AC OZC.0100 or 21C 021/D Well Conwrwcn.rrn Sfiwtcktrd,
annd thw a cnyoy of this record has brew irvv ded to the well ouner
Sb.Latitude and kingironit•in degree%lininutrtlsecond%tor decimal degreef
(ifwcll rcld,ota Ln ktug w a1111Ctctn1 9•Site diagram or additional well detalls:
You nta% use the back of this page lu prin ide additioml%ell site details or%ell
-- * W abatidouniteea detads. You nnnan a6o aftach additional pgrs if nnecessan
CONSTRUC77O% DE LAILS OF RFLLASI BEING ABANDONED SUBMITTAL FNST1tUCTFONS
.iffikh re!!rna,fru.In•rr m—'i, :!mwhd�h Par'ovampi. ——n r.urr .1,14) -
nc•11vOALI'rnhfhr.elmrctonerN( vnnc.m'whmaronei,nM.. loa. For All WeMi: Submti tits form wvhin ;ti d:ns of congAction of%ell
6a.Well IUm:
e-18 abandonment to the follfncmg
Di-,hitlo of Water Rewturtx�.Information Processing Unit.
6b.Total wdl drpdt: 39
1617 Mail Srnicr Center,Ralci.-h.M'276"-1617
1ft.1
IUb.For Inityl on Wells: In addition to sending ilk:form to ilk:ddness in lua
abo%c- alw sidnnu one copy of this form%tdmn +ii da}s of conipleittn of%ell
tie,&nrMrlr diameter.2 tin.l abandommuctu to the followune
DirWon of Water Rewsurces,Uudergirimed Injection Control Program.
6d.Water k.rl below wand wriacc: 10 (ft.) 1636 Mail Scnice Center.Raleigh.NC 276"-16M
) Ilk.For Water Sunmh & Inketitnn Wells: In addition to sending the fort to
w lit
6e.Outer camng length lifkin ni: the address(esi above, also submit one cop} of this fort %illun nit da)s of
completion of nil abandrnmtent to the conun} hmhh depmnmert of the count}
where ahanndonned
6(.Innrrcasin�'robint:lentKh(if known): ($.)
6g,Screen Ienulh(if Mon n1; (R.)
Foam GW-lo Nei-t 1,I:nwl•r 't;ie et n ca of Emt n ommen and Natural Resotaces-Dn lsion of Water Rcwokei Rn lead Aupm 20111