Wake_Well Abandonment_20240903 (9)

WELL ABANDONMENT RECORD for ltrre IVio:ONLY
Thi.form,;an be used for single or multiple wells
L NaH of antraet„r Information., WELL ABANDONMFNT DFTAII.S
Scott Hunt, Jr 7a.Number of wdls being abanduned: 1
Well Cotrtacror Name Inf Well uW rot frrsotcdt}almA&)1unL!Well on hntar plopcm r F w mrinph a,le,lnxr r,w rim-,t,rrer strl14) -ell, n.VU -oh llk- .,to,r
c.drrrna par r�innhxrnm.n , n u.,xlorur.xrr d.rn�
4561A
lh.Appntzitnate rulunrc of water•remaining in Avl1(,i0 1>tal)
NC W"ell Cnnlm,p,r(..gin ntw:rnr„r N,m#,cr
SAEDACCO FOR WATER SltPPI-V W F.LIN ONLY:
7cT.N for ofdr.iofcctantu%cd: •''" i' a-- '>
2.W di Coastrvctiun Pa•dt N:, S E P ,J 2 24
!ltl u!I,tpp(kdt lr well prrmj1x n.e.C~o,.x;ah•,t dr a-e Imeo.w.. i,. l Amrvrr
7d.Amount of di.infcet�n x t u •d:
J.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that appiy is
❑Aerwultural ❑Municipal.Public N Nett Cement Groin rl Rcruuute(hips or Pellets
06cotherrmil(Heating+Cooling Supplyl ❑Restdcrital Water Suppl lure Ic) ❑ Sand('enterN Grout ❑ Un(la}
❑hodusonal("ontmcrcial ❑Rnodetm:d Watcr Srgtph Ishared1 ❑Concrete Grout ❑ Droll Cuttings
011notation ❑Specialty Grout ❑Cirasel
Non-Water Supph N,ll ❑Bentotute Slum I Other(explain under 7g)
sklomfonne ❑Recusen
Injection Well: X Forea('It nratt•riat K•lectt 1 AMC.pnrrsidt'arrnnrnt lif materialsevol:
❑AqutterRecharge ❑(iroutdwaterRemediaiton Neat Cem. :941b ,Wtr:7gal. _ Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Recrn en ❑SAinm flamer
❑Aquifer Test ❑Sfortnw:acr Uratmwc -
❑Eytenmenial Technology ❑Sulomdence C'ontrul ?g•Pruritic a brief description of the iihandonmcmt procedure:
❑Geothemtal lClosed Loops ❑Tracer
location was over drilled and pvc was removed from boring;
OGeothcrnal 1HeaUn 'Conlin Return) f]Other lei am under 7 ! —
tremie grout location from bottom to top
4.Date w cll(s►ahandoned: B-5-24
5a,NNell Iraalion:
Brownfield Road Landfill
Fxihtalmotifaptow") S•Ccrtif)cmiori:
2600 Brownfield Rd. Raleigh, NC 27610 8/7/2024
Ph+weal Address.(m.and Zip -4x(.steo!'�'estd;/dv Cnntrxtdr err W'etl(h+rrr [Pare
Wake &'signotow this form, 1 hereby cerrrlf Aril the wellfsr was(were,ah ni timed in
kJ:nbl,.nxni No.(PIN) aczv►thonte with 15.4.'CAC OI17.01 of)or A' O21t0 R•e!I COnWv(-n... .N(an(kjnA
and Aso a copy of this rerord has beet,trot ided to the well owner.
5b.Latitude and Inngitr(k in dcypeeslminutrslsmtnds nr decimal dtgrres:
(if well fcW,ore 1:100rtg n wrliutcnr) 9.Site diagram or additional well details:
You owl one the back of this page to pins ode additional cell site details or well
N W abatdonniera details. You ona% also attach adtlmonal(rages it necessan.
(ON�TRI( IION DETAILS OF N EI_L(S!BEING ABANDONED SUBMITTAL INSTRUCTIONS
.(nd,ir nail u,aVrudanr nm,urdds,it d,whPh,. :-,w malrrp(e age,rrrar err ma-wiser rapp(r
nerlror"t.rn,rl the.rant„acerr,wutdhmekmmmetwcm,stmu.rwH.,n. [On. For All Willi: Subtrut this fomt utthin (f dais of completion of urll
,.a.Nell IU>r-
Lott-Pl7 abandonment In the follouing
DisiAun of Water Rewturces.Information Pntcc%4ng Unit.
n.b, I�rt.d Hell depth: 35 IfY)
1617 Dail Service Center.,Raleigh.NC 2?6"-16I7
lob. For Isleetioo W'dls: tit addtlion lu wndutg the form to the address in lua
2
abu%e_also subntu one cM of this fonn w w within u)dass of completion of well
eC,fttmlarlc di:uuCttr: (in.►
:obatdonnnrru to the fullouutr:
Disislon of Water Resuurorn,CnderEnwnd Injection Conttvl Program.
6d Water Ich'd hrlme f0nend surface: 10 (h-1 1636 Mail Nemec("enter,Raleigh.NC 276"4636
Iffc•.For Wafer Sunul & Inicrtitn We11s: In addmom to sending the form to
(,e.Outer CA-Any length lifknown): (h•) the addresses) abo%e. also submu one cop% of this fornl within iu da%s of
completion of wdl abadonmcni to the cotuYs health deparinrettt of the coum
6f.Innrrcasing,+tnbin>:length liflarnwn): (tiJ
hg.Screen length lif knowni: (h.l
Forms GW-3,i Nirnh C'an,lltu Lkpannrtt of En,trunnen aid N:ntur3l Rcwurccs-Dh(stun of Water Rcsoarces Ref Wed,Utgust-t)I i