Randolph_Well Abandonment_20240910 (4)

WELL ABANDONMENT RECORD rot Imcni d usC oNtlf:
This fans can be used forsinate or utulliptt:li%
1,Wet!Contractor Information: WELL ARANDONMENT DFTAIL.$
Tyler Brown Ila.Number of Avi'lls being aliaudim ll: l
�ti'clfCarimetorNaaic.(artirllow pam�allyul>amidrdsi;\�eil.dnhisfttsrpiapcflyl For uiuhrpk, tttfeelion or Mrr-uttfef +sup'pk wells. ONLY-'wtRi Ilk .setae .
cmtfrrretirxr:ribmrehNina^rt,,tr�n cvnr.rrtentf'rxrefonn.
4625A
NC r�rcu GbntraaarCenifipHou Nroi#tcr 7b.Allpto utlxtC\'alums of tint' minaming in wcll(.r�•5 (gttLl
sr EDAcco FOR WATFR.SUPPLY WELLS ONLY:
Cxittq:mq Natac 7c.Type otdisinfectant used:
2:%Veil Cousttvction Permit 4:
LW aR applttubl�_ueilPMAY q.v.CwjrMI,Stale,11urtoraee.Brfeclimr,rdri tflawwa 7d:Amount of Wslnfechlutllsed:
3.Wclt use(cLeelc\fell uu):
Water.Suppty Well: Za Seating mutcdalsused(dices;:ill thin apply):
OAgtfeultitiat I7hltinicipallPtlb)ic. M Neat Ccmcut.Gtout M W ttotiite Chips or Pellets
gGcothcrmat(Hcatine*Caolhio Supply) []Residential Watcr Supply(singlcj '13 Sand Cenral Grout 17 My C 4y .
❑lndristrial/Cornmcrcial Misidentlat Water Supply(sliarod) 0 Concrete Grout ! d'Dritl Cultings
❑bri lion b Spertin IV Grout C3 Gravel
Non Water Supply.WcH: M Eentotute Slutty 0 Olher(explain under 7g)
29Mmiilorine.-. 1311ecovery.
Iujcction Well. 7f.For each material selected above]prncidc amount.af:tiuitedils used:
OAgntfcrRkcharfe 1301,0m1dt\IICr1ZN11tC{hllhntl Neat Cem.:941b ,Wtr:8gal. !• Sand Cem.:lb ,Wtr:gal.
i]Arinifer Storage alki Rectn•ey l7vitdty Barrier
13A0ifei Tess 0Slonnivater Drainage
Bentonite.:10lb ,Wtr:gal. ;
t7E Vetinietual T&Ituotogv FJSubsidetxe Cottiml. 7g,Provide a brii'f description of the;abandoutncut prncetlum:
C1Geodwrinal(Closed Loop} Curer
Poured bentonite chips tolbottom of well to the top of the
dGeothersttal(Healinit,'CoolinR Rehtm) ®Othcr(� lain under 7R) .
screen and tremie.grouteq4n; 7_—
4.Date nrll(s).hbandoned: 8-22-24
5a:Wen Iocation:
Powersecure rn ,fr'.Y`7•t•
8:Certification: ►f! " .•. :- .
Cat7itl•/OunerNamc Fociliti•IN(ifappltcablc) i t�i�wo�•>'`o
1410 Coltrane,Mill Rd. Randleman, NC 27317 13 8/22/2024
Physical Addms.0i 7,ondZip or Weil Oinur Date
Randolph B3'sww"g this forfo.I bemby cerdj:thud slag irell(sJ tiros otwM)ahandoned in
Couaiy Petrel ldsulifboitinu No.(P4Nj ac..urdance with 1 M ACAC 02 .01 QO.hr 2C.'0200(Moll Cw1shitclion Startekirrls
grid drat a copjroftlris"record has•been prorided to the well riwner.
Sb,,Latinideand longitude in degmatinioutes/seconds or decimal degt'ccs_:
(if�erll 11561d,one bitiong is stif'r3*1.4) 9.Site diagram or additional well tlet:tits:
You mak use.the bars:of this page to pr6vide additional i\ell site details or\ce11
)\ W. -abatidoiunent details..You may also attach additional pages if neeessary-
C.6N`TRif(-r10N.nFTAti S OFIWFLUS)MING ABANnONt n STTR11tTr.M,INSTRUCTIONS-
:Itrl.Yil%'dj,cvrsLmciAw trrurd(s)if avwld ik. _)'fir 11arlrlfltC f11�eL♦1flR GI'f�)f!•11Y7117'.LI(� - - ,.
nrtla ONLY uirlirlx same muarluritlwrefynn 10p,'Nnr All Welk -.,Submit this fornt uiddn 30 duys of_complction of well
6a.Well El)#.MW-2 abandoumcitt to rho falla\ving: i
Dicisitin of Water Resnurc�,Infotmution•Proc�.4ing IItdt,
45 1617 NNH Service Carter`RLdcij 4,XC 276999-1617
6b.Total well depth: (It.)
1.
10b.t:or•Trilecllon Wells: ht addition to setiding the fotmt to the address in I0a
Gc.Borehole dirttuctet 2 (;n;y abo\V,ALSO subudl otte cope of this 1foriir\4'ithiu 30'days of campletion of\i'ell
trhunilonnteui to the follatvitig: _ !
i.
22 Di\islon of Water ResourrLs;6iidergrouud Injcct(ou Conirol-Praoraru,
6d.Water tevel.bclaw ground surface: (ft.) 1636 Mail Scnicc Cctiler,Raleigh,NCG 276994636
Go.Outcrcawrglcn length(it known): (ft) loc.Fnr•Water Surinlr A.inieetin i Weliv: Its addition to settdhtg the form.to-
the addwss(es)abow.'also submit one copy'of this form v6[pin 30 days of
completion-of\veil abNndomnent to jthc county health dcpm nncrtl of the"comity
\\•hcrc utrtndottcd..
6E Inner w.Ain�„/tubing rength(if known): (ft) i
ft Screen Icngth(if huonn):10 00
Foarr MI-50 Nonit Carotin Mintuncat of Enviroomcnl aril Natumt Resewces-Division of Wnwritesi antes Revised AapW 2013
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