Alleghany_Well Abandonment_20241001 (2)

WELL ABANDONMENT RECORD For Inkrml Use ONI Y
This form can tie used for single or multiple wells
1•Well Contraetcir Information: WELL.ABANDONMENT DFTAII ti
Rich Lemire 7a.Number of Wells being abanduned: 1
well C'oomanot Nane nor hell ohnf personally Amahuung-well on hsdr(prgxm i Frlr mufbph aiµ,h,w ,w MNi-MUQY rki phi .06 ONLI wrh ,lk
r'.Nr.lilac(J•MI�ilh1M'h Nlgh/l(,IIIN 1i01+Nl•�Mr/.Nfi M1lr/H
2593A
lb.Appri%imate% re vhrtof wattr remaining in hcll(.1PDNE Igal.)
NC Well CorgrtclorCetift lion Nrnilcr
SAEDACCO FOR WATER SUPPLY WELLS ON1.1:
(o mponr Name 7c 1'.�Ire of disinfectant vmd:
2.Well Construction Permit N:
LA&idl a*kvbk well&rw as u.e.Ownn•Smk.J unra vi:v-Lgeoinl%eta.r 4 berwn 7(L Amatnt of di-sinfe^cwnt u.evl:
3.Well use(check Well ore):
Water Supph Well: 7e.Sealing materials used(check all that apply):
❑Agmultural ❑Municipal-public v Neat Cement Grout ❑ Henforitc Chips or Pellets
❑(irnthermtl McannG+Coolinc Supph J ❑Residential Water Supph isinglc) ❑ Sand Cement Grout ❑ Dn Clam
❑hdustnakCommercial ❑Rcudennal Water Supph(sharedl ❑Cottcrrie Grout ❑Dnll Cuttings
E3 Irriavitift ❑Specialt%Groul ❑Gra%el
Nnr-Water iupph,Wen: ❑Betxrnule Slum U Other(explain under 7u)
HNIomtontig ❑Recmrn
Injection Well: ?<For each material sekscied abosc,pnnide annunt of materiak rued;
❑Aquifer Recharge ❑ mundwarer Remedimion Neat Cem.:3761b ,Wtr:24gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage aid Reecnen ❑Salirin Darner
❑AgntferTest ❑Slorrm%aterDratuage Sentonite.:71b ,Wtr:gal.
❑Expettmemal Techoolog% ❑Subsidence Control lg.Provide a brief description of the ahandonim•nt procedure:
1.1(reofhemtal(Closed Loop) LITracer
i IGeothenitil(Newlin -Cooling Retum) tjothcr 4explam Wider 7 ► TREMZE GROUTED FROM BOTTOM TO TOP.
i.Date Wcllls)abandoned: 9-10-2024 •/ 1.,
ia.11rllhicanon: OCT 2024
SDWY 7947
Faiably ltrnetNafc Facility WO(ffrpplicahl,, a.Certification: IfrEj:Ph..i!: t�'r,^3r�'.tyl+tiT
CG
306 N. Main St. Sparta, NC 28675 'h t ..f/l'wws. 9/14/2024
Ph,sical Addrc%s.C 1t1•oral Zip 5lcicrtiue of. :ff><d W'eR l'nnirxMr rii W¢R(h%rut Daft
ALLEGRANY lii .%igning this Jnrm, I I meby cerh/%that the wellfsJ was(wenei abividoned in
t'awrn PJIIeI 1&111110.3111111 NI, WI]I aexonhatur wiNa 15.4.WAC OX.0100 or 2C• 02W Pfeil Construction Stcmckin/.s
and that a copy of this record has been provided to the well owner.
Sh,latitude and longitude in rleMvcniinutrv%ccond%ur dmitial dtyirccc
Of well F.Ad.one Lit long i`wafieictai 9.Site diagram or additional well details:
You ma% tee the back of this page to prrn We additional%ell site details or%tell
11 11 abatdonnterf details. You tna% also attach additional pages if necxstan-
(OV,I RI( 110\ IIIJAILS OF W EL1aSi BEING ABANDONED SUBM"'TAL INSTRUCTIONS
.:[t.xu .,u,.ualrrL,::nr rrwrhs;is al wlcrh;y. !vv m1J(ti:1c r!yn(1:nr,v ra•m e.lrcr wpph• -
weikONLYxith ,uhmilcvwhume IOa. For A11 Nlicfii: Sublral din firm Nldian 10 days of completion of%%r6
6a.Wetl[DI!•
SB-2 abandonment in the following
Diwishm of Water Remiarces,Information Pracv%-Ang Unit
1617 Mail Senior Center,
6b.Total well rk)rih: 25 Raleigh'NC 27699-1617
I06, For laiecties Wells; fit aMition to seidutg the fornt to the:ddtess in Ina
r1e,IkirrMile diameter:2 (In,) abmc_aLw subnir our cap\ of this form%Ylthun 10 d:ns of conipldion of tell
:ahardonnieru to the"ImAuig
Dhision of Water Rewurcrs,IL nrkrgnfind Iniaition Conlrvi Program.
6d•Water Mvcl hirllw Initund wrfsee: 19 (ft.1 1636 Mail%mice('enter,Raleigh,NC 27699-l&%
length lk.For Water Surmth & Inieetiin Wells: In addittoo to-,awing the form km
6c.Outer eosin
g gth iif hmoWa): (ft.l the addresses) above. also subnnt one copy of this form cailhni ill dams of
completion of wdl abadrnuncnt to the :ourvm licalth depannicn of the :ouri%
6f.Inner casinr'robing length lif I:paw n 1: 15 ft.)
%vherc abandoned
6g.Screen length(if Lnow n 1;10 A I
Fort GW-M) North C'arohm Depanuvn of bo irommiu aid Nniurnl Resourecs Dn islon of Water ReNourc.s Res sed Agnsi 201t