Alleghany_Well Abandonment_20241001 (3)

WELL ABANDONMENT RECORD po,,,,kn,,,CQcrN,y
This fonn can be used for single or multiple Hells
1.Wen Contractor biftrnnation: W'FLI.ABANbl1NMFNT_DETAII S
Rich Lemire 7o.Number of trdls bring abandoned: 1
WC11 C'otrtactoa Nary tot%Cl1 rw.nY pefsotully attartdxntxg hell an 1115410 property t Pry mnlnph oll' brow ar rWW! dfe1 sulyA wells ONLI rrrh Ike xWte
r'rN{<frNt flr Nr rd4tM'h NINx'IN.WN"M,Nhmlf rA a Fran
2593A
Nxxiur N(-
7b.Approtimotr vvtlraer of water remaining m ndllsiKO +gal.!
Wcp Cnmmclnrt:�cHifsalnn
SAEDACCO FOR WATER SIIPPLY WFLI S ONLY:
Comm%Namc 7a Type of disinfectant used:
2.Well Constractiun Permit N:r
lw rdl gy4uuhlr trellll-rmrt,me-+'wNf,.Sr.Ne.I nnarnee.lnfaafurn•nr.�J Anrnn 7d.Amount of dhinfixtanl used:
3.Well air(check well nsr►:
Water Supph Well: 7e.Sealing materials used(check:all that apply):
D Agricultural 01Numicipal.Pubhc M Neat Ccmcn(Groot ❑ Hcaonnc C-h"or Pellets
❑Gcothcruml(Hcanrky Coohng"Aipply I ❑Rcsidcriml Water Supply+singic) ❑ Sand Cerneni Grout ❑Dn ClaN
❑lidustriaUComnicicial ❑Rmiderau it Water Supph i sitared) ❑Concrete Grout ❑Drill Cuttings
❑Itti •till ❑ Specmin Grout ❑Gravel
Kon-Water Supph Well: I_) Hetaonite Slum C)Othef(explain under 7g)
19hionitonug ❑Rttioten
Injection Wed: 7f,For each material sckcted above,provide amount of materials wed;
❑AquderRecharge 06mundumorRenitedianon Neat Cem.:3761b ,Wtr:24gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Recur en ❑Saloon Barrie
❑Agmfer'1'est ❑StonmtaterDrainage Bentonite.:71b ,Wtr:gal.
❑E.Venmenial Teclraolog% ❑Subsidence Control
71; Pmide a brief drscription of the-ahantionment procedure:
❑Geothenrial 40osed Loop) 1_ITracer
TREMIE GROUTED FROM BOTTOM TO TOP.
rlGeothemtal(Hcatin +Coolin Relum) 1-10therieNp4arn under 7 i —
1.Date pelhsl ahamlouetk 9-11-2024
....
ta.Well location.
SDWY 7947 Ifs.v:R lt:f : r� "•'aa tiisr
S.Certification:
Facilrry,puttcr Nuns Farcilih WO(if ttatlicabkt
306 N. Main St. Sparta, NC 28675 '� � .irj r,, : 9/14/2024
Ph.sscal.Address. aWZip Seeeaftxrtof 1..:ilioOtMepCptygeeatorWt110over Dent
ALLEGHANY By signtnX this fix-m I hereby cer A,thin the wellfm teas(We►tei i6tvhhNaed in
l5r,u,h i�tt.l Id nntnatxiu N. ;t'I�i tacrorthhnce with IiA WAC OY.O100 or Y' 0_V0 Well Consim-h'on,%attltards
imd Ihrat a cgpv of this record hru been pn ri-R d to the to ell owner.
.Ali,I.Atitudc and longitutk in 4t wevininutrcl.wainds or dtt•imal dty;rccs:
Of acu f0d.one Livioug K millu:wty 1 9.Site diagram or additional well tk•lads:
You may use the back,of this page to pnn de addmonal evil site details Of well
N W abandenntetn details. You may also attach additional pages if net;tssan.
CONSTRUCTION DETAIL N OF AELI_+SI BVIN(:ABANDONED SURMiTT,• L INSTIIU)CTION
.tfWalr rrf7 cnnrlrL[h+nt mn,r.l o-;!;arwhAhh' 1•rr nnrlf!pii rlyir Bcnr IT w,n u.ua:r cLiyir
vie ArONLY riath rAe wNxr twnhreNewer r nnkaNnrta/.iim can whmu cute Axm Iota. For All WNcllt• Submit this form witlun 10 days of completion of well
6a.Wen ID#t•S8-3 ahatdonnicnt in the following
Division of Water Res+mrcm,Information Processing Unit.
Tots)all depth: 25 h.)
1617 Mail Smice('cater,Raleigh.N('276M1-1617
6b. I
lob. For Inicclion Wclis: in aMili ni to soling Ilk form to Ilse addicss iu loa
alwtc-alai suhnm ale copy of iln n w s fon ulinu lit days of cumpleion of!tell
tic.Bnnitoly diameter;2 Lin.) abaudonntem to due following
Division of Water Rrwmrces,I;ndc-rgnuund Injection Control Program,
od.W au r kyti hcltrw girtntid surfan: 19 (ft.) 1636 Mail Scrtice Crater,Raleigh,NC 27699-1636
Inc, For Water Sunoti .tic iniectiom Wells: in addition to sending the fomu io
6c.Outer casinn length Iif Ion"a): (ft.l the address(es) above. also stttnmi one copy of Ibis form within it) tms of
completion of well abaridmiotent to the county health departmeta of the county
6f.Inner casinY,'Yntrin>;length liflmown): 15 (fl.l where ahmodnticd
6g,Cereen length fif known);10 Af
F"rv.t A%-,rr N.mh C'arclon Departinera of Em nomocm mil Naruml Rcwxmcs-Do%isior of Water Resotmvs Rc,ised Atigaisa N)I t