Caldwell_Well Abandonment_ (3)

r WELL ABANDONMENT RECORD For Irflum]Uw ONLY:
This tbirn can be used fbr single or multiple wdis
1.Well Contractor information: WELL ABANDONMENT DEfA1L5
Scott Hunt, Jr 7a,Number of wells being abandoned- 17
%VOIC.natetcior Nam(or wadlottttefNisquallyalmniionWg wall anhWlwpropeny) Fm mulople oytcuae or noa-ireUcr supph, wells O,VLY IsrAt 11M swne
core rirrcpai,rn6wrtlnvunerat Iran aarsalun�rwieforan
4561-A
NC Wall Contedoor Coil iew,41don Number 7b.Approximate volume of vrater remaining in wcll(s):
SASDACCO Inc FOR WAUR.SUPPLY WELLS ONLY:
Convany Name' 7c Type or disinfectant used:
2:Well Construction Permit k:.
List a Jl fappkevhl�.wrf!permlAx ti.c Cwara(v,Stute,Turd uric.laJ.c flnt,NIC1 tfkaroarn 7d.Amount of disinfLuant used:
3.Well use(check well use):
Water Supply We1L 7c,Scaling materials used(cbeel:all thilt apply):
[]Agrifiultttral []municipal/Niblic la Neat Ccment.Crrout 111 Bcutonitc Chips or Pclicts
[]Geatheund(Hcatiue)CAo(ina Supply} []Residential Water Supply(single) ❑Sand Untent Grout ❑Dry Clay
❑hdustrial(Commcrcial ❑Residential NVatcr Supply(stared) ❑Concrete Grout ❑ Drill Cuttings
131ni tioD ❑Sp&jalty Gtout ❑Gruvel
Nett-Water Supply.Wcll: ❑ Bentouite Slurry 0 Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 7f.For each material selected alcove,provide amount Of materials used:
❑Aquifer Recharge ®GrnundnWer Rentedialion
1JAquifer Storage atxl Recovery QSaliuity Barrier
❑Aquifer Test ❑SLorinwiterDmirnage Bentonite.:30 lb per locationlb ,Wtr:gal.
❑Exrerintental Ta Amotogyv ❑Subsidence Cautrul 7g.Provide a brief description of the abandonment pr ovoure:
OGeothennal(Closed Loop) []Tracer
Injection points abandoned upon completion. Filled with
®Geothetlit~t[(Iieitti 'Caalin RentmD ®Other ice. laiuvnder 7 } ,
ti.
betonite from bottom to toprz
4.Date well(s).abandoncd: 5/4/22
5a.Well hicition:
LC Hudspeth lnfOfW 1 PrOMQV,1g Utz
Fao)iit oU wtxrNMM Facility IN Cfapplicablel S.Certillcatiou: [�Lzr€`�t V5�
5891 NC-90, Lenoir, NC 28645 ��'� � 5/21/2022
Physical Address,Citp,and Zip 5tyln:acarCeriUitd Nett Ca aunt urlVetl fhvaf r Dale
Caldwell )Jy,signing thislann, I bitchy certify that the rrellfs}was preen)abandoned in
Couniy PM;d lda1IJffib6lln1LNO.(PIN) racwrrlrrlace iville l . iVCAC 02C,0100.or2C,020a 1Fell'Crri.vi tlrriatt stortrhards
and Arta a cgpt'ofllris record has been provided to Me ivell owner.
Sb..Latitude and longitude in dcgrcesltnirtutcslsccondsordecirual degrees:
(lrwell ruAl,01W tarltpaig is sodiletc110 9.Site diagram or additional well detalb:
You tray use the bail:of this page to provide additional ttell site details or well
A' W abaudountent details. You may also attach additional pages if necessary_
CONSTitI1G_MON DETAILS OF WGLUS)BEING:ABANDONED SURNWMAi.i1VSTRUCTIt}�l'e
titrada trrl!noaavtrucilura nx-OrdFxl Jf dtroU&J14..1. Fear muhiple/utlecticue or min. -wair suppli
1w#8ONLY pith alas same arucinnrtaaan4abculihura.lcrat,lrxa cola urbatria are fottrc 19a. For All WeMs: Submit this form within 30 days of completion of well
6a.Well ID#:Bl-Bl7 abandonuiciit to the following:
Diyition of Waiter Resources,Information Processing;Unit,
6b.Total well depth: 16 (n,) 1617 Afail Sci-tice Center,Raleio,NC 27659-1617
10h.F r Inlee(ion Welts: In addition to sending the form to the address in l6a
6e.Bar ebale diameter:2.25 (io;) above,also strbudl one i:opy of this foan within 30 days of completion of well
abandonment to the followiut:
Division of Water Resources,Underground Injection Couttitl Program,
Cod.Water level below ground surface: M.) 1636 Mail Scrvicc Center,Raleigh,NC 27699-1636
Ge,Outer eosin length(if k 10c For Water Sutnill& hrgt�rtton Wells: In addition to sending the form to
l; r�( nnRo): (fG) the address(es) above. also submit one copy of this font ttithin 30 days of
completion of ttdl abandonment to the county health department of the courtly
wheTa abgndoncd,
6f.Inncrrasingltulting;l'ur}Kh(if Imuwn): (ft.)
6g.Screen length(I£knoiva): (fG)
Fame G%V-30 North CaroUna Degnnmcaa of Environment arxt Mfluml Resoimes-Division of Water Rcsoam:s Revised August 2013