Rockingham_Well Abandonment_20241001

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WELL ABANDONMENT RECORD 1 r-j-)
For lakrntsl Uro ONLY-
This form can be used for single or multiple wells
I.Well('retractor Information: WEl.l.ABANDONMENT DETAILS
Stefan Smith 7a.Number of wells being abandoned: 42
Well Contractor Nan►tom Neil ow m►'T perseunall.abandoning Nell on htslrr propem I Few r»nluplr utlel fru, tw .e.n-rdk•r eels ONLY' with the smote
t'..,titer,(l.Nt 1 r1`11.hit.l,n.'nr I..n,rut Ykhlnlr'a. l.,e,n
3576A
NC Well Contractor Certification Nnnnbet 7h.Appnrsimate Intense of water remaining in%c110.1 /A (PM
SAEDACCO FOR W'ATER SUPPI.1-WELLS()NUN':
Compaa)Name
7c. Is in•of Jtattfeetant used:
2.Wdl Csastroction Permit 0:r , R10400627
Lot di.µpeefrr Well♦.•rout.(Le. n11M.Sidle.I imair'e /median.etc..ItInr•.. (I. ,inllmint of di.inftYtant uvJ:
3.Well use(check w ell use):
Water Supply Well: Te.Sealing nmatemials used(check ill that apply):
❑Aptwuttoral ❑Muntapal,Rmhltc 0 Not I cnicur(..nwt ., -. �i f!i i.ei.onite Chips or Pellets
❑Geoth rural tHcannG('ooling Supply) ❑Residcrnal Water Supph 'singlet 0 Sand Cement(gout •-.• • 'or .l1tyA'lay
❑Iidosinal.Commercial :Residential Water Simpph(shared) 0 Cotktete Grout Q C T J 1 202 Drill Cuttings
❑Imgation 0 Specialty Grout Gravel
Nee-Water Supply Well: ❑Bentouite Sly(\r.�;. i'� --�y ..�IO9(explain under 7g)
❑Monetonog ❑kecosen
Rejection Well: 7f.For each material selected ahowe,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Renmedtation
❑Aquifer Storage and Rrcos-erg ❑Salinity Hamer
Bentonite.:51b ,Wtr:gal.
❑Agnikr l'est ❑Slommater Drainage —.
❑Espcnntemal Technology ❑Subsidetrce Control 7g.Provide a brief description of the abandonment procedure:
❑Geothemmal(Closed Loop) ❑Tracer
poured and compacted using DPT rig. These are injection
❑Geother al(Heating,Cooling Return) OCOthertexplain under 7gI
points abandoned when boring was terminated.
4.Date nabs)abandoned: 8/14/2024
ta.Well lot athln:
Wheeler's Grocery
Facility-vOwnst t' F.t.itn. if applicable). R.Cetlifkatitar:
9385-A US Hwy 158 Reidsville, NC 27320 8/30/2024
Physical Address.Cn),aid Lip 5'-Ann:—Cenifted Well Con n:actor or W'ell Owner Dane
Rockingham Bn swim*:this form. !hereby cernjr that the we!!(si was iwere,abandoned nr
I Vat“:1 ldealth:mminn No.MINI accordance with lt.-1.VCAC 02e.0100 or 2C.0200 Well Construction,4andtirils
and that a copy of this record has been provided to the well owner.
5h,Latitude and k.ngitude in degreeslminutealtcco dserdechmal degrees:
(ifaeli tick.one lai)ntlg r suilitactat 9.Site diagram or additional well details:
36.289806 NYou gas use the back of this page to pros de additional well site details or well
79.735080 W
abandonment details. You tray also attach additional pages if necessary
CONS-1 Ni(7ION IlLIAILS OF\\ELIAS1 BEING ABANDON SURMITUL 1NSTRUICTIONS
.tt4xir neil cy,as:rM.:(r.,,erns,'.:-1 ell whe'dr. :.rr nniihoic tyre nun or rein-toter wppir
ne•U.O.YI.Y n,1h the genre t,orortK(e,.r oean,F.rrmrra.loft ran nihmu one N!nir his. For .All Welty Submit this fon)! within 7,0 daps of completion of well
ba.Nc41 II),:_ - IP-42 IP-1 abandonment in the following
Division of Water ReWaurees.Infunnation Processing Unit.
61r, 1617 Mail Service('enter.Raleigh.N('27699-1617
Total well depth: 23 (p,)
!Ob.fur(election Went; In addition to sending the Comm to the address ut Fos
Anne.se. also submit one copy of this Donn ssnhw 30 days of completion of :sell
roe.Bnrs•Ipil•diameter. (in.) abandonment to the following
Division of Water Resources,Underground Injection Control Program.
ttd.Water level betnw ground surface: (D 1 1636 Mail Service('cater,Raleigh,N('27699-1636
Itic.For Water Sumii & Infection Went: In addition to sending the form to
Inc.Outer casing length Of l.nmmss nl: (ft.) the address(est abuts. also salmi one copy of this form within )u days of
completion of ncll abandmuncnt to the comm.health depanto n of the:omits
ss here abandoned
ef.Inner casing.tubing length lif known): (ft.)
Screen length Of Loon nt: __(ft.)
Enna GW-lit Noah Camino Department of Eti.ironulte:a:nil Naturol Rewur es-Do teen of Water Rsoiuees Retteed August 2011.