Durham_Well Abandonment_20241001 (3)

WELL ABANDONMENT RECORD Fell litertnalUxGNIY
The form can be used for single or mtdliple Hells
1.N,cll(fintractar Information., W'E1.1.AHAVDONM1IENT DETAILS
Brian Ewing 7a.Number ref wells being,abandoned: 8
Well Cottw itIt Name lot well ow na WrAoulh ahaMomng well on hterlicr properrs i 1 u- rvulryrla rnlecu(ur fr 'irm-oater Slrlln/r hells ONLI veth the rldnlr
f.„tir/,tf,fl,Nr.�•,1rNI wnh'/N,Irrry lfU1.YhMflr,Nfe 6"m
4240-B
76.Appnninmatc lolurwic of waur rrnnainin> m wcllh): Ig1aLl
NC Well C'oMradcrc Cerllfralton Nnn#+n
SAZDACCC FOR%ATV R SUPPLY WELLS OM A:
Comm pao)Naar "c.'Type of dtdrmfectarit used:
2.W(dl CMatnretbn Pe'vrlt N:, , WFI0501142
llsr,dJ a*&ohl. uvl! I.e 1 r 11,.shoe. Infe,hon,el—rl Amen
"d.Amount of Jiunfcctant ux•J:
J.Well use(check:w ell use1:
Water Supinly Well: 7e,Sealing(material.used(check all that Apply):
❑Agricultural ❑MtmrupalrPublic O Neat Ccmcm Ort%a M Heruomic Chips or Pellets
❑(ieoihemtal(Neamn'Cooling Supph l ❑Rmidcratal\Filer Supph lsinglc) D Sand('edema Cimut ❑ Dn Cis}
❑lidusinak Conlnicicud 014mideralal Water Sntpph Islwred) ❑Concrete Grout ❑ Drill C'uttinp
❑Inn two ❑Spmvdn Grout ❑Gras el
Non-Water 1�upph%%cil: ❑Benlonue Slum I Other(explain under 7g)
❑NIonllonne ❑Rccusen
Injection Well: 7r.For each material w4cctclil almac,prnc idc aniiumt of materials wed:
OAyuder Recharge ❑Gmundiater Remedtatton
❑AAlutfer Storage aid Reccn erg OSAImrh Hamer
Bentonite.:501b ,Wtr:gal.
DAyumfer fell ❑SlonmsatrrUrauwgr
❑Expinmetttal I cchnoog.% ❑Subswdeme C'on iml
"L.Prot isle a brief darcriptian of the,Abandonment procedure:
I_IGemlhemutl(Closed Loop) I_tTracer
HYDRAULICLY PUSHED SENTONITE
1 IGwillenual(Heaun Coolie Return) II)Othct(explain under' ) I(
It
i.DAtcwclllc)Abandoned: 8-28-24
5A,W'rll lowAllon:
Malcom Pinkston Property
Facilit),0%wrr Nurr Fxilov ID MI(if applicabk) R,Crnilkalidm: .• .a
1915 Chapel Hill Rd. Durham, NC 27707 _Brian Ewnp 9/11/2024
Ph.steal lddress.Cm.aId ZIp Aettaiiire of Ccrldkd Wen('mitrrcMt :r r.',R O,rrrr Dale
Durham Bw .signing thed ftwm, 1 hereby verify that the wellfs) wax twerei a witilo red nr
I u a, I'a;0 1tk nI A!: ;i n i No MINI ac<anlame with MA.'vC AC 02C.0100 or X' 0.0)Mril(i!nsirvulion.Vimckir,lr
and that a cvM of this record has been prot•rded to the well rw'ner.
Sh,I atitudc and longitude in dlegivir tminutectsacnnds nr dec'imal degree-c
(it well field one hn,long t,+nttktcral 9.Site diagram or additional well dl•ta0s:
You elan Inc the back of this page to prrnide additional hell site details or well
abatldounient details. You ma% ALSO anach xMitklnal pages i1 rkccssan
CONK I RI( Ill N Dt:I \ll.S OF M EIJAM BEING ABANDONED SUBMITTAL INSTRUCTIONS
f l,h ii M.,, i/rt.,!�L.I••rl IV, ,It, ti i'rV rfiir!fl/,l('i/lril tl,ref,U'1Y41 ,il,T snpphv
xellr fl.Nt.1"„Irh the.%iPnw,.t %&m vim oh(vfhrvn evif.low cum whmv wte hmn 111a. For All W clLs, Submit this form within 30 days of completion of nYll
Ills-A-1 - A-15 (ODDS) aNindcnliicm to[tic follduung
ire,�1c11 )
Dii ision of W titer kemiurces,Information Procrssing Coil.
(lb.Total well depth. 18 (rl,) 1617 Mail Smiee('cuter,Raleigh.NC 27699-1617
Inb.Fur lakWou Welli,: In aMilwu to sculling the font to ilk:ddmcss III loa
ice,Burrhldr d►ariteMr:
2.25 (le-) ahme also subnul one copy of dos form%whin 10 days of cumpletion of»ell
ahardonnicRu to the lollouuitt
oil,Water k�ci below Dh6lou of Water Resources,l'nder•=nwud Injection Control Proglrave.
ttnwnd wrface: (f(•1 1636 Mail Smicc Center,Raleigh,NC 27699-1636
length lac.For Water Suenh A Inicetilln Wns e : In addition to sending the form to
(W.(later cadn
>G ngthIiflmowe): (ff.) the addresstes) above. also subum one copy of Ibis form %ilhin In days of
completion of well abandonment to the cowls lteahh depannria of the county
6f.Inner casine,+telunL length liflara %httc ahordnriedNnl: (R.1
6r,Scm-o length(If known): (h.l
Form GW-(lw Noah C'arotttn Milminem of Ens wommea aid Natural Rewirnes Dis iuua of Water Resouk'iS Res I"Aqua_101A

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�.c's. ) 7;!.j)trtt t•itlC abrief de+eriptign;rl'I l,c abn.nd o,�.:'enc�,rrzrccciuuc
1'ai:Cr
— ,ti.t:-a�(�aurs I�etl�<n.i 'JOtt:_r(cxplaiit under 7;•} � l r � ��JJ�•�,//�
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`f..i' a• �iIIaprild(ifauplisablc) 3�icrliGcation:
or c.a 1 wC conrrtaor ur Well
_ !7r.oyueiy this./arm. I hc+e1)t'car r1v tl.ar the u'-�m'pa/arvrr
Parcel ItICIlb11c,111011 No.(PIN) accard—co aid,15.1 NGC 02C.6100 n.'t llt f C1x+sr.::; rCJ
arirt darn a copy of thia recarcl hay ha.'r/prar,cterl fa.r1r,1 nnrrcr.
�:,.:..::if;:;:::1:::J Ina�i:ude in degreeshaiuules/secouJs m•dreiaml degree+:
9.Silt di:%pniiji nr nddilinaal well<tcta.i.v:
You MIRY u:c Cic Lack of this you ,:to p,nvidc it'.Lu'urr:xnLI Fitt
J sbaudoumalt details. 1`ou may ai:n�aLu:L a�'.iliti,.:V.:'; .L i +czm=Sj
i ION D TAIL$QD 1vJ:Lf.IS)BEING IJr\IVDONFD SI1RIti11 I\5fR[1C J'I[))5
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IUa. For All MI1s: SUbIllit tilis Ibru tl i:: e,i
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Division 0M.Ilcr ltctatlrecs,frit,r
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