Randolph_Well Abandonment_20240910

AVELL ABANDONMENT RECORD � For Imcmal Use ONLY;
This foim can be used fir single or inulliple isells
I
1.Well Contractor Infonnation: )YVLL ABAy, nONM1IEF�-N-TT--nn•-l--;--T--AA•-K--A��
Tyler Brown 7a.YtiniherofivellsUcinaapaudanet 1
Welt CantmdorName(or ual6%vw persa![lll} on ltisr"plumy) For w:dopkr PJ feEwol? or' V011-mite malls ONLY w lb .Ihe. ruJie
CM1SNPiCrlrN1�171t/01Ni'iNIlJJ[RJf,)VN C[aP.SUTAJNi LYIC"f,[JRJI, -
4625A 41 {
NC 1Wl ConiractorGSttlitcaliotr Mather
7b.Approitimate"InHIe Ofttatta'rtvn! tininR in�rell(S.)V A ()Gal)-
SAEDACCO FOR NVATER SUPPLYNVELILS ONLY:
Company Name lc.Typc of dWnfivtant used:
2:Wetl Canstructlmt Pet mltA,
LW all apphiwblewelllrarmlls(i.e_Gwan,,Slaw,1'arJn,xv.hbwuar;N1d!fk- )%srJ
7d.Attiount of dlslnfcet int uK4l:
3,Well UA!(eLceletrcll use):
Water"Supply Well: 7c.Scaling materials uwd(cliccic all That appiy):
gAgrirulttlraT phittnicipallPtlUlic W Nat Ccmen(.Gmut 13➢cr4onitc Chips orMllcts.
❑Gcotlicmrtl(Hcatittr�Coating Supply) p[tcsidontitrl Water$14) }(single)
❑Sand Cc tent Grout ❑Dry Clay
❑htdintriallCoiiuttctcial- ❑Itcsidential Water Suppby(shared), ❑Cgncrete'Grout i ❑Drill Cittlings
❑Irti •tion ❑Specialty Gtortt '❑Gravel
Non Watcr Supply Well: ❑'Bentonite Sluny " . ❑Other(explain under 7g)
P9Matilinrittg.. ❑lkewvety
Injection Well: 7f.For cads tuatcritd selected abot c,'•pi-oxide amotint of nuiterials of ed:
❑AquifcrRccbarge, ❑Griiuiutgleer"NrntedLilioti Neat Cem.:941b. ,Wtr:8ga1. Sand Cem.:lb ,Wtr:ga1.,
CAquifer.Stonrge-atxl-Recoven, ❑Salinity➢ardc.r
❑AiiniferTest ❑Stomnr°atert.Dntftiaga .
❑E gxtinwatal Technology OSubsidence Cottittul.
7R.Pro vide a Drlcf d6Crlptian of the,al►:itidnnmmt prncitilure:
Men ihermat(Closed Loop) ❑Tracer
Tremie.grouted ao om o5 to,surface
.17Geotherttial(H6fin 'Coolin Rctarn) ®Other(ea lain under7o) . ,
r^Z
. VC'
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d,nat.c ivell{s).abandmrotl: 8-22-24 S E P 1 0' i�24
5a.Well lucaNnn:
PowerSecure
FacilityiChvner N:ure Fxili r llls 06pplkablc) �8.Cet'dlicali0h;
8/22/2024
1410.Coltrane Mill Rd. Randleman, NC 27317
Physical Address•City,yid Zip' Sf�rnlnrL orCePtiPurl tVen GJJ:4q;tor or well owur Date
Randolph By sigifing this form,I lmneby certifl.'Mot the srelifs)was prere)abandoned i
Count%. Panel ldcrwfbt adau No.(PIN) irervMfilte with 15A ACAC 02C.0109.tir 2C.0200 117vil C•anslnrcuoys Rafirkmis
and ilral tr crp},of this record leas beVi providcd fa dre o-ell owner.
Sb.1.:atitude and longitude in"ticgreePlminutes/sccondsbr dccini,ol degmce.
(itwell reld,ow ladlong k ati:lticsew) 9.Site diagram or additional tell details:
You tuap use the back of dtis.page to provide additional itell site details or rsell
1\ W abut doiuuelit-d'etaits.,You tuay also ailactt additional pages if Itecessas<_ "
CONSTRUCTION[IFTAII C-01?WELtd41 BEING.ABANDONED SURAtTTPAT,MSTRUCTIQN, I
:ttLrtlr,lirlJ,wasrrucllPJrr ra[welfsi!f'dunllrzrtla. l�ev m>tlNplr iJ�1rJPP"ur Ja}Jn•uiatir suFP1J' � � •
nrellsONL1"irltlirl,w svn:ecvJuuckttoJe zrrmrrh»ri!teru1+JumnzrbJniecurejOnM 10a:'Nor Ul'Wells: Submit Ibis£Hint witbiu 30 day5 of completion-of well
Ga.Well ID#'M-7 abandonment to the fallurving:
DMA6n of WalerResuutrc5,"lnforawtino ProMWng Unit,
Gh.Tatativell depilu 25. ( ) 16I7 A1ail Scivicc Curter,Ralci�h.ICC 27G99-161?
tOb.[+or Til Icclion Wc11s: In addition to sending the form to the addles in.10a
above.tilso s
Ge.itorehole diameter.2 (;u; ubtidt Otte copy of this Bonn stitldu 30 days of completion of well
} abirndonaiein to tite f08owing: '
i •
Gd.Water lerd.Uclon,�veund surface (ft.) Division of Water Rcsourres,Uudetgrouad Injection Coutral Program,
i636111A.Scnicc Ccri,I i•,Raleigh,XC 27649-1636
Ga outer cash toe rnr W:iter Srmnly&-Tidecrinu Wills:,In additian'to.sending the fomt to
g Icn�{rf!sown). (tt) the-address(es) above. also submit oue copy of this folio within 30 days of
comptctiati.of.r�A abandoiunent to the,county henith dcparimetn of the county
Gf.Inner wsinotthiny(length(if lntarso): (tit)
wlrrrc abandoned, -
i
ft Screen length(If Imot►n); (fey
Fomt GWAO North Carotlm Depoaruem of Environment and Naturrt Resoruecs-ah,islan of MacrResal rn.s Eteviscd tuprsr 3D l3

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NVELL ABANDONMENT RECORD" rat trddirml ft ONLY:.
This form can be used for single or nuthipte Wells
1.Well Contractor information: -)FLL•ARANDONNIENT DETAlf 5! !
I
Tyler Brown 7a,vtiwbirofvvillsbeingabandunc : i
�Yell'Coutetcfortrat>ic(arxrllotrn�pcaonall}'alundoPiln'^,vrcllonhisilrrpropcny) For Pri,rluph r,jeruwP or ra,t-iinrer, sup'F , malls 'OYLY wuh Aw swiie
cmurnrcfr�ur�mba;P�huirmwar,lYlNCtUP,srtuiur�ejFin,i, '
4625A
NC'1\'CI1 CanlydctarCCttlrir.�lioti Nnti>bct 71t.AliprnirLnati valwnc at vtntu rettwtuing in vti ell(a):16 (gall
SAEDACCO FOR WAM SUPPLY NVELLS ONLY;
Cotupan+Name 7e Type of dhinlectant used:
2.Well Construction Pertult 9.
Ltsr pll appflea6fe f�eNlar,rril.(ie_C.rue%StQk,i'uNamci:L�rctim,,,rlcl ff Gm�ng
7 d.z►triotmt of tllslnfLvtunt usLv1:. �
3.Well use(cbcdchell usij:
Nvater.supply Well: .7e.Scaling rnated4s-used Rkel:all that apply): -
QAgriculttual. i3municip,•tltl'rtblio M Neat Ccmcnt Grout ❑Hcntonitc Chips orPcllcts
rickothctm d(Hcating1coolitio Supply) pttcsiiletiritelWatt r Stippl}(ringlc) ❑Sand Citit*Grant ❑Dry Clay
❑ItutiisttialfCvtnntcrcial ❑Iicsidrtitii►IWatcrSuppl}(shared), ❑C611MIe.Gto111 O Dtill'Cattinp
❑ini tion ❑Skmalty Grout ❑Grdrel
Non-Water Supply Well: ❑Bentonite Slurry ❑Olber(explain under 7g)
I9hlanitoring ❑Recovety.
Injection tYctls 7f.For Bath material selceted*abOve,�provridg auiontit of.nuitMals need:
❑AgitifirRichatge ❑Grouiidtivaer}3cinedlittion Neat Cem.:941b ,Wtr:8gal. Sand Cem.:lb ,Wtr:gal.
17J1gniferStOmgd atxl ReCOVVY ❑Salinity Barrier
❑Aguifet Test ❑Stommuter.Dtattiage
❑Eyvetintetilnl TecUttalogv pSubsidettet CotNtul 7r,Provide a brlif descrIptian of the abandonment pr(kwvlun:
❑Geothermal(Closed Loop) Mracer
OGeatttertn altlie<itinWCoalittRReiam) ®Otttcilax laiaiunder-7s} Tremie grouted from bottom' to surface
FR
�" lQ
4.natIewCH(s)abandonedd: 8-22-24
PowerSecure .10W 1:7s+
8,CcrllRcatiair: D'rY-
racilitl_iC war Nana; rxllkv IDs(ifappiicablc) f
1410 Coltrane Mill Rd. Randleman, NC 27317 !✓' �"�~ 8/22/2024
P1Avsical Address.City and Zip 5i,rctlP� atiPe+1 We]t Curur+ear ur tVell�era5r Uale
Randolph Hy signing lhes Joan, 1 hereby ca,tify.lhar the ire/l(s).wdx(tcvre)abandoned in
Caaiuiy Parcel ld,,,06 0ttNo.(PINj octuirlan a With 15A X'CAt 021C.0100.0'r 2C:0200 Tfvl:a. ;Jslnrcuon Stawkirils
aril that a apt•oJllris rccard lrm beE�i pmviderlto Ifievell owner.
5b,i atitiede and longitude in dMeeslmlituteslsecondsb ees r decimal degr : ;
(Ifii•ell few,or,e latjtong is 003001,4, 9.Site diagram or additional well details:
acl:of d6 page to providi additional well site details or well You tuaprrse the b
N W .abudounteni details. You luny also ankh additional pages if necessary.
CONSTRi1MON nFTAIL•S OF WirLt %UPINt'.ARANIION.En SLTRNiiTAL iNSTRUC IONS•
:lrfotlr ur1J evruirui7ie,re n�ivra!(s)1J•awti11a2Gla. l'vir hwlupre i�jeetlaara'w'awn•usrtir sapplt' �•
nx11s ONLY idthd snnerwrsrrncfemNa?,undrnliscr,i iaunmsubaniewreh-n IOa:'Fnr all-Wells: submit this fntnt svithiu 30 do);- of completion of urll
Ga tVc11ID11• _4 abandonment to the follovving: i
Dhiyirin Of Nutcr Rcsnuirtti,informntioo Pipci scing Unit,
l61711Ini1 Service Center Raleigh 11C.27 699-1617
6b.Tatalw•illdepW: 55 (ft.) ti :' " '
IOU._For Tn IecQon Wells: •ht additiou to sending the forni to the addtesi ki 10a
6c.Borehole dameter.2 (iu.) above:also subnd(Otte bopy of Ibis ifoitil witbih 30 days of couipletion'Of vivll
abiindontitent to the follOwing_'
6d.Water terd.bctan srviurid surface 54 (ft,) Divistott of WnterResouriis,Utidergroaitd itijectionCotttrol Prdgram,
1636 Mail Service Ccritci•,Raleigh,NC 27659 1636
l �
6c Outcrc 1wi Ica dlativvn): (R.) lOc.Fnr Water Surinh'8c tiiiccrinn Welly; In addigan'tei sending the form to
1: ( the address(es) above."also submit lobe copy'of this f�oun within 30 days of
compaction of_vvell abandintnlent to hire Comity henitb dcpannCtit of the eonw,
6C Inner eavin;jtnbin„tength(if lmown): (ft)
wherc alnndoncd,
ft Sert•cn length(if"Own),n):15 (ft.)
Foray MI-30 Noitti Camlhn Dcponmem oiEniironmcnt and N:uur3i Rmimes-Division of WaterResmuces RM15ied A gmL4 20 t3
h �