Wake_Well Abandonment_20240910

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s''WELLABANDONNIE. Isl" .T RECORD Ccf.a/-:hrldriud VW ONLY: .
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This:farm can be used for stogie or tutthipte Went. i • . •
. • , •I.Well'Cantractor Information:-
WELL ARANDONMENTDETALLS
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. • Tyler.Brown 7a.Ntimber Of wells being abandanctl: 1 • • • • . .
WcRtimlideiortisniO(or walOst ea pasOnally dianiOn143 n lt oll.an lier Orgies)) Forh finiple- .htige iton or rm' rtoiure; Isup.ply wells-.:ONLY with ire-,&Mk.,
coniketchoivilhairdaiiiiairnti itleOeun sulni4t0/te:Airnr:
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4625A .-. .
. 7 .APpr4imate,triuntief wait:Tv:431'th*in.Well(s)1 - - COO
NC Well ConitseMrCeniticatitin Niniter • • . ' • 1: . . • i
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• -, FOR WATRR SUPPLY WELLS ONLY: • •
_SAEDACCO • .
• Company Name 7e.Typenfdisinfectan1 used: ... 1 • _ . __. . _ • . . .
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2:Well Construction Pernik 0:, , - . • .
lia all viiptkapkwell pv.rodir-irt.4...CToray,4'Nt0.r:Parraoc:e.iltf:Orlicit7,,.It.)tylienen . Id.Amount of disinfettliofos4
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. • •.3„Widl uSe(elm*.Well,use):
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• • WaterSupply Well: -. - . 7..e.Scaling materials used(check;ill that apply); . .
• - ' hl Hermariite r IS orteliet •I 14/r L.,,..;
itliy,ricultrunt ohltiniCipaliPubliC: • Cl Neat Cement Grout .
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• °Geothermal(Ileatingr0.0iiiii1SliPply) • 0Residentiat Water Stip*(single) .- •Cl'.s.lilici•c'1*91i Grout , CI Dry Clay
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0 habistrial(COMintemial•• • ClResideutuit Water Suppl)(shared), .0 ConcreteGrour . ', U Prillgiiiill0 S E P 1 0 424
0 Ittifintion• , . .. - • 0 Specialty Grout, i 0 Gravel
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Non-Water Supply Well r 0 Bentonite Shiny , CI•Other(ekVilliitiiiieFfar rr-47•4i-AgT".1 UP3
' • ' • . Vtl.OPIGia"
.111Moilloring . . . ,• 0Recovety ' • .
Injection Well: .• • • • -• . • ; , - , •• ,- • ,• 7L For each Materitd selected above„,,proside antomatal materials used:
I:Aquifer Recharge 0Gthundwater RentediatiOn ' . ' . •= :. . .
OArtnife`r•Stonige and.fieccr.H.etY ligalinity liarrier . - : -
• Bentonite.:151b ,wtr:gal. IL '
Ofiaptifer Test • : 0Stonnwater.grabiage • . — •
...... . .
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•
. . 0E:vent:let:MI Technotoev 0SubsidenceConiml. 7g.provide a bricf•d6cription of the abandountent procedure •
CIGeothennal.(Closed Loop) . 0Tracer • .
• Pour bentonite chips from;bottom of well to surface
i3Gtoteimai(Hmtine/Ctioling Return), . 00ther(mplaidunder 7g) . .
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4.Datervell(s).albandoncd: 8-27-24 • . ,•
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a,-Well lecithin: .' . . . . .
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. Old Raleigh Landfill #6 . • . • . . - - • •
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Fiacility./0-wour Nunto Faeft 11111(irepalkablO) cer tillelloin. , •
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1850;Fayetteville St. Raleigh, NC 27603 Wake Count 8/27/2024
PlisicarAddress.City,Snd Zip . • ' SidUlurir of(*.citified Welt Coni*.tot or%%Nit On-mr Dame
Wake - _ . ' ' iljt siring this farm; :1 hereby certif,i).ilurt the welIN 11.17S ere)abandoned in.
. . Conan Prime]titnitifialauNo(PIN) 06.0.111a-in.!?ivith"15.i1l'AVAd.02 .:0l00.or 2t.d.700 IVell'Cpiisfritction Standard
' •anddriit a cam oft/us record has been provided(Go the is ell firmer,- "
Sli,Latitude and longitude hi,degreesholuntestscenndsbrdetiMatdegrces: • .
(tf11'411 field,one larihni2,is snilli411) -9.•Site diagram or additional well details: - .
.• You may use the.backOf hits page tc.provide additionai.isll site details:or well
• . . . . • N • . . W .abatidotintentdMaits.,You may also'attach Alilionattiages if liec'essalY- •
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CONSTRUCTION DETAILS eiWEEL4'§i RUNG:ARANRONin SURNITITAL INSTRUCTIONS..
f Iyatir.leAff c'teurtectidr.z ratitd(3)it available.'.lim'suldtwee hyrdiAirl or r rid a.11 Ttlir.T.IlMy
Well;ONL:yiriO 10 funie,,,iorsirbegq.feabeitgloiehieTityqu ono rhniii.ckqe finie._ . 10a,For All Welk:: Subtint this(ban Within 30 days-of•eouiplction•of Well
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6a.Well 11)#:74-1 • " . mbautionnient to the following: ' ; •
• •' Divisien of W:tter ResanemN,Inforntation•Proctssing Unit,
6b.Total well depth: 10 , •- (ft.) • 1617 111aitScrviczeciit.6.;Raleigh,NC 276994017 •
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• - • lOb.For In Icetiott Wells; In addition to sending the form,to the address itt'Ica
:thew;also-'submit one copy of this forth within 30 days ofcoMpletion of well
6e.13oreltole diameter:2 • . (in.) .
'abarsiotpuen1 to Me followiu*. i:
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• . . Division of Witter ResOurio,.thidergsputuf injection Con trill Program,- .6d,Water level below ground surface: 5 (ft.) . 1636 Mail SeiTice-C+tr,Raleigh,NC.I276394636'
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• 10c.Far WAter.Surinlv&Infection Wells: In addidOoldsemling the formlo
6e:Outer casing length(if known): 5- • . VC) . l4.0c1clrets(es) above, also submit;one cap of this than within 30 days of
' completion-ofweli abandonment Co ilic•calmly health department of the county
. • where abandoned,. Ii
6f.Inner casing/tubinglength(If.hmown): • (&)
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6g.Screen length(If ktiotir):5 - , . (ft.)
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Fpna aW,10. NontraroUm Depdrimers of al-MI.011min rusi N4urut Resources-Division of Water Rcsotirms• . Revised Augus1•20 LS
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'WELL ABANDONMENT RECORD. For Intenuil•UWONLY
This.form can be used fer.single ornuthipte well*. . • •
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I.Well eintractor,Information: 'WELL ARANDONMtENT1DETAtES i
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Tyler.Brown . • 7a.Ntiniber Muds being abandimod:1 •
ltirg'It Centraelpr.Nailln(a etl mita tiusuit.itlyrattininilligeoll.On tiistkr plainly') MY raufol* Iniaddli; or' rienmivir,er I.sifgl'' wefts'.'ON ' 'with 11N •mole
' • constracnonlabairdoinnent,pin can subaaroneftwm,
4625A • l' : .
74.Apprii*imatisolunte nf*MO remaining in Woll(s)i 32 • .- (04
NOVO CottimoMrCeilltiCanotiNuither
-SAEDACCO - , . ..
. FORWATFA SUPflYWELLS,91I.it
Company Name le.Type ofilisinikaani uScd;. . r . . • • •
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2..Well Construction Permit 0:r r . . . . .
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Litt all io,uptkepleweltperead(i.e.Canny,Sii4.fariartc4 pleitiata,.dici)if knaunt . • .
7d.Atnount of disinfectant used:. l' • • .
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3:Weitusie(cheekneli use): • „ •
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Water Supply Well- - • • 7e.Sealing inalartalstiied(cheat,:all that gmily): - .
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Itftricultrtral IftiArtnieipal/Puldic, CI Neat Cement.groitt • : ' DI Bentonite Chips
fr-.:Pallats: „.;..*-). I,..• -r..,.
,.,;.... ..,.,(...tICycothcortat(Heatio&Ceoling"Slippiy) •CIRcsidential Water Stitvly(Single) .13*11411C"tOkt Cr.9t't ; CI Di Clay -
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. ' phalastrial/Commeseial- I:Raider:Oat Water Supply:(shared) ID:ConetetoOront •e3 brill SE P 1 0 2024
ClIrriotian. • . __..._ • - . I]SPecinity Grout - ' !', .1:1 Pravel .. . .
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Nog-Water SupplyW4:- . . -' .17.1 tlentonite Slurry • Cl Other texplaitiloilice4git's7B t's-",..F...2.P.igFe-,U-PIX
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. ggildlitiOrillg , glilecovety. . . • DWC.-itIOGI . .
Injection Well: . ' ' . ' - - - - , . • . • - • 7.Foreach material selcctettabova,provide amount of.Matetrials uSed:
ElAquifor Iteeltarga 12Griitinduatei Rentadiatioti
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DAttitifer Stptagiand kee.ni,.v.iy • :.ligalinity Barrier •. . . • - '
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Bentohite.:151b ;Wtr:gal.; . .. .
13A.OnifeiTeSt • ' ' . . EIStartinpter Drainage . . . . •
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1:3Eximtintental Technology. jiSubsidence Control,
7g,Provide,a brief'description Of the abandnnment procedieta: -
E1Geotherinal(Closed Loop) ElTracet, ,
Pour bentonite chips from'bottom of well, to surface
EIGeotheitnat(HeatingCnoting Return). . Miller-faplain under 7g)
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4.M:de-well(0.ithanilaned: 8-27'24- ' .
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- Sa.Well tocallon: ., , . .
Old Raleigh Landfill 46 • . . , •
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eillf1Pat ion:
Facility/Ovum'Name . Facility IDN til .8;C
applicable) ,. . , . ..
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1850,Fayetteville St.,Paleigh', NC.27603 - , . : / : . 8,27/2024
Pl4sical'Addras.-City.rand Zip - '-Si atop:of Certified Well Contain:kw or Well Outer Date • .
Wake. . , '. . By.stgning this ppm,I hereby certify that the well(s)was(rate)abandoned in
Catiaty ' •' Parn0 lilantitiainn No.(PIM' ' navtdance With 15..:4:',,CAC 02e;010:tir 2e.0200 Well:Colislivelign Standards
• . ' and that tr dopyOf this regard lies be&a provided to the'Well owner.
' .5b,,tatitude and longitude In tlegkestiniOntisisciondspc dieiMtdritegreesi
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(Ifuell Fteld,One latilmigissuMalcq) ' 9.Site diagram or addltionatlyeli defogs: - . •
. • ..• . You •use the.backof this page to-I:reside..additional sell site
trrOderails.or well
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N. • •-• . -W .abandonment details.:Youll:ay also ortaell additional'pogesitnecassary. •
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CONSTRIICTION.I3F,TAIES 014EI.LiSt BEING ABANDONED •- SURIVITI'TAT.INSTRUCTIONS.
mach.Well.consenetioe redwdmif available. •Fite nrultipir attedtan'or rion•Forfr sappij) ' I
ivelOpAir iro the 6.17111 Onstroenontabaittioninenr.lull can subnittcwlfank. 10;4;.:FIlr All-Welly Submit•this Bain within 30 days:of completion of well
tthandonnicin to the folloiving: !:
6a.Well 1134:*-3 ' • . .
• , II fyisin n uf WaterResonretN,Information-Processing Unit,
db.:Total well depth: 10 (ilt.) .1617 Mail Service tenter;Raleitli,NC 27.699-1617
101i.For.Tnlec lion Wait In addition to sending the form to the address itt.10a
above.;also submit one bogy of this forth'Ivithiir 30 days of•-eintiplelion.Of well
6c,Boroltole diameter:2 • (in.) . •ahandon llt ment tae following;following; • '' •
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-Division af Water Resoured,'Undarground Injection Contt4PrOgratn,
gy 6d.Water level below• round sturfacei.2 (ft.) 1634 IStail Service CeUter,'Itaileigh,NC 276994636
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10c,Foe Water•NOOnls-'S:hilectimi Wells: In addition to sending the fomtio
60..Outer easing leap&(if Imown): 5 (.4) .
tit4.'address(es) albure.also submit i one copy of this thrill within 30-days of
eompktion of well dbandoiunciit co I th'c cuing):barn depaitinent of the county .
where abandoned. -
di.Inner.casitigittibing ttnigth Of Limn): IN •
. 6g.Screen length(if Moul):3 (ft)
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Folio OW-6 Nan!:Carolina Depattmenlof Envitonment and Natural linsolutes-Division of Water Rcs niNn Revised August 20 15
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-. 'SWELL ABANDONMENT RECORD For Went!Use ONLY;
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This foiittican be'uwil..fai siogleor unilillite wells
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1.Wet)CotitractiTtlifiirmatiott: WELL ABANDONMENT DETAIL
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Tyler grown . , . 7a.Number iiiwells•being abanilaned:I- . - • .
WellConoectorNente(or wit Ouro-fersaaehy.ehendenisig uellon hisiller proprrty) For opfroplo 1 rijecdon or mon,144yr I sjqipty- •4fells ONLY . with th e..sikie •
constrection5b9neleimete;pu cot mthailitionefiref.
4625A . • lb:AUprokiinate minute of water remirining in Nivii(s)i . ' •. . (01.)
. . t4c•w0tCoiniraclarckii.tifrOoti'N'Tviter •
siEDAcco FOR WATR.sprfl..xwgr,ir.s...019.v:
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C,onspany Nome • [ :
• .7e.Typ,eirfdirinfectant used; . . , . _ ,...._ •
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• 2:Well.Constructiort Permit#:, , • • • I. ' •
• Lu!all oppheattletivtl pirreits CLO...C401n1Y,-$110i,Pal-mar:4 htlectIon,,ek.ktftztenvq• •- 7d..mtt.ottut iirdisittatililit...used: !• ,.
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3.Wikkus.k.-(00i.1.,e1;!lit): - . . • . . .
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•Water Stipply•Welb. . . . - ' . ' 7e.8aiiiiii 01:i; ri;ii..okil(Chcji•ali tli.itt aiiiii..):
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EilgriCulttital: 6MOnitipal/Publio: CI Neat Cement.Ocoui . . i . - lfll gentonite Chilcerf911A...p...t,
. - 0eltootcrind.Gicati4Coolifig SIOPIYI 1:111:csiclential Water-Striiply(single) El Saud Cement G turit - : O. ..,,.
,Dry Clay , r‘L.: ,C.:V r-.Li
. .. bliaiiistsfal/Conipterolai °Residential WaterSupply....(shiired) 000n4eteOrout. . ;• -It'Drill Coal tigs.
• ID fitieittion-. . . - . - . . . . . b.S*inlkii'qroul, • CI Gravel ,: ' • . SEP I 0 424
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Non-Water Supply:Well: - El Bentotute Slum . • a Other(es-plain-uKIFS 7,1,
..t.:r
. itilMosiitoting- . - 1:litecovety. • . . . - . rit '171;c9.1-7'''' •
" . • lojection•WO11: • :, . .. -. - •-• If:for-each uthiterhil seletted ithoye,provide amount Of.inaterials uSe ,
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ClArprifet iteeitaigi. • ' - EIGreuridwater Reirtribitimi .-' " ,, • -, .
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It Aquifei-Stootge ant RedoVeky CISaliiity Barrier . . . . • . .
. . . Bentonite 151b Wtr:gal. -- .
CAnnifer.TeSt . • 1:1Stommatter Draitiage• • . .
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.0ExPitillteillal Techuoioz, liSubsidencetouttul. 7 g.Prirride a Itrielvteseription ctf the altatithinnignt-procedure.- •
Cfgeolltermat(close4 Loop) . . IlTracer . . ' .. ' . . -
Eour bentonite•chips. from bottom of well. to surface
• . .CGeothemtat(Heating/Cooling Return) . C .OdiellexpLlid .
under 70 .
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4.Bite well(s).abandaned: 8-27-24 ' • • •
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Sa.Well Location: •
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Old Raleigh.Landfill #6 •, , .- • • . • • .
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FacitimtbruerName Facility110,,(ifiipolicable) . Cerell.icatioit
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1850.Fayetteville St. Raleigh, NC 27603 - ,,,. /.: , ..' 13.-72------7-
. . ..... d/27/2024
.P4Sical.Ad5re .City,'atid Zip . . . . ' . Si_iol nFe.of Cotifi4d Well"ceittlacteret Well th'.nir •.pate
Wake • • -
- - -. _ , .8}1 sisigng,thts fire:,1 hquby Certilielturt the wai(s)ifiiS Acrer)ttbattilaued•itt
County • Pmvp1 IdatitiliCatibit No(PRVI necorylailtv will,IS1-ArAc.02d:0101):or2C:0200 WE.11: vitstiudion Standards
• - - .. • • ' ' . •and that a capybilhi s-mon,.f has pOtprovideif(a the tie!!owner.-
, ti,Latitude and longitude litilegitOititilittitesfscion4orifeeinttti'4eireesi •
(tfsell two,one latilaitgis stiffleletip 9.Site diagram or-additional well derails:
• • . . "You mac;use the.bad k of this page to.Otavidd additional iwelt site details or Will
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• • - N * .abaudoiuuetildeMils..You may also attach addiliopal.pas if trecessat3',.
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• CONSTRItCTION.IladTAILti(rEWELLLS)BEING'ABANDONED •
•$BEINIITEAL INSTRUCTIONS 1, '
:Wath 141.F9fiAtractich?recviii(o'lt avtiitob Ie. Fa'multiple ittjectite f'tir rien,!ettit samiy
"44 WO 011"?' sg?"'':"1"'W(1491/6-50.06Y.',1e"i•j!"cu"'lib*o'iel?".1- - - :' . 10a;Fur All-Wells: Submit-this forin viithin 30 days,of:Completion of.well
6a Well fiiih'114-2 ubatidounientto•the following: ,1;• '. .
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pOilicin cif..74.racer Rest.c ,Itiiohnition PrOci....iipg Unit,
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db.-Total well depth: (It.) -
- 1617 Mail Ser-yjce-tenter,101eigh,NC 276594617
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• . 10h.For.1n!talon Wells: In addittoir to sending the form to the uddiesi.ht-Ica
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'above;also•submit one,copy of this foitii.vithiü30da of completiofi.of Well
Ge.Borehole dlittteter:2 - • • (111 .
4.
' ' 'ithittitlotsttcsi te'dte fedlswiegt. ' ! '•
Divislmt of Water.Resouriesi.UMierground InjectiOn control•Pregraitn,
dill.Water tivel.hchrw'gruund surfireei.0 • (ft.) 1636 Mail Service teittdr,Raleigh;NC It.499-1636
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10c.'Fnr wove&tapir•,y;firiectimi Wells: in addition 46.seirding the form to
6e.Outer.ea-sing length(if lornwri)i 3, • (ft) - .the address(es)aboye also submit one copy of tills:foitit within lt!-days of '
compietiori-of well abandonment toIthe•county health department of the county
where libmitioned, • •
6f,inner itasituiitubing length(if(mown):. - (ft.) •
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. 6g.Sereen length(ir Idiots-0:2 - • (ft.) .
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Femi GW-,0 North Carotim Pepattmera otEmimemett and Nattplitesonices-iiivisto it of Water itcso tdpes Revised August-20 t3
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WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Fe it) ye, C. b ip5 7a.For Geoprobe/DPT or Closed)Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2-7 65 l44 wells abandoned: I}
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): Z l 7 (gal.)
uC Tip✓' P W e"I 5 FOR WATER SUPPLY WELLS ONLY:
Company Name 1 H T - .
G, / `,Z a �a -ZiZN 7c.Type of disinfectant used:
2.Well Construction Permit#: W
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifknown i ' L. 6
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that app ):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout ! entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) 0 Sand Cement Grout ~T .-,4.- *1 •❑Dry Clay t. L.,i..
S •/i'.-L
❑Industrial/Commercial ❑Residential Water•Supply(shared) 0 Concrete Grout 0 Drill Cuttings �;
• ❑Irrigation • - 0 Specialty Grout - - 0 Gravel - S E P 1- 0 L.y24 '
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery Ir, : i,. ;. i3r.47.4-„7-;y Ur
Injection Well: 7f.For each material selected above,,provide amount of materials 4➢s" P:40`"
❑Aquifer Recharge ❑Groundwater Remediation ' 12 b i7
S * Bps- -l�iale fit '
❑Aquifer Storage and Recovery ❑Salinity Barrier - . - _
❑Aquifer Test ❑Stonnwater Drainage
v
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer I 1
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) ��S• PbPefV-if e- 1 T �" �-
4.Date well(s)abandoned: /��2Y 2V Py5 6,-4 Nal.e Ptky
5a.Well location: ,
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1 0?Pe e" at..: l 0( d r,
Facility/Owner Name Facility IDti(if applicable) 8.Certification:
itS 6 G rA k�4% ,Jc 'V " Re,d L�� (9 - e/6/z1
Physical Address,City,and Zip SignatA of Certified Well Contractor or Well Owner Date
kAla iCe_ 'signing thisform,I herebyce'rtt that the well(s) was were abandoned in
By 8n g .f' (were)
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C J0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram oc additional well details: - _
N W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)dfavailable.For multiple injection ornon-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: ` (S (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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6d.Water level below ground surface: 2 O (ft) Division of Water Resources;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniectiori Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.) ,
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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