Caldwell_Well Abandonment_ (2)

WELL ABANDONMENT RECORD Bur ltticmilUscONLY:
'ibis form can be used for single:o r nathiple►tils
I.Wcll Contractor Information: WELL ABANOONNIENT DETAILS
Scott Hunt, Jr 16
%Vc1r6uteac1orhante(orkuAlotiviicrpeaonallyaWnilgning%cllonhfi0herprcpc�v) Ar irrirlopl fri�'itai & rmi-iivrer sirpph- wells ONLY wah MY same
eautnretrorr'uGairctnruu ref,ie v car srrf�rdf Lft?ftormn
4561-A
NC Wet1 Coutm:lor Cegifi Lion Niunbcr 7b.Appnrxmiatc Volume of water remaining in u'ell(s)i
SAEDACCO Inc FOR WATER.SUPPLY)MI..S ONLY:
Company Name 7e4 Type of disinfectant used:
2:Well Construction Permit 0 .
Llxt r ll nNpll+vhte arllpurmirs fi.e C+wal}t Slt3it,T'urtrrrxx,Lgectinr,.N1CJ krNiSYr 7d.Amount of disinfectant tt5ed•
3.Well use(ehed:well use):
Water Supply Well; 7e.Scaling materials used(ebeclz all that apply):
17AgricttlturaC p]VhmicipalEPttblic ❑Ncat Ccincut Grout. ® Bcntonitc Chips or Pellets
❑Crrnthcmrat(RcatinreCoolin Supply) ❑Rcsidentutl Water Supply(single) ❑ Sand Cement Grout ❑Dry•Clay
❑halustriallComntercial ❑Residential Water Supply(shared) ❑Conciete'Smut ❑ Drill Cuttings
limeation ❑ Specialty Grout. ❑ Gravel
Non-Water Supply Well: ❑Bentouile Slurry ❑ Other(explain under 7g)
❑N101iitoring ❑Recovciy
Injection We'll: 7f.For each material selected above,provide amount of.materials rued:
11A41rifer Rccltaigc MGround titer Rentedwtion
0Aquifer Storage attd Recxn'env pSalinity Ranier
❑AiluiferTest ❑StornmaterDraitatga Bentonite.:25 lbs perlb ,Wtr:gal.
❑E.yterintenlal Twhnotogy ❑Subsidence Cant)nl ?g Pet►- a brief d6criptian of the al►and runcnt prociedure:
❑Oeothentral(Closed Loop) ❑Tracer
Injection wells abandoned upon completion, filled with
Me+othemrat(Hcati Caolin Return) ❑Ottter(er laiuunder7 )
betonite from bottom to top.
4.Date well(s)abandoned: 5/3/22 t:. j ,'
'i
Sa.Well locat-loo: 202Z
LC Hudspeth �
FaadlityQhvncr Native' Facilitti•1Ud(ifappinablc) R•Certi(It timu: '�C; s�tt^rL� +,w71
5891 NC-90, Lenoir, NC 28645 �cetty�u .t- 5/21/2022
Physical Address,City,w d Zip Wctl soli 'ior or We11(rivwr r Mae
Caldwell lay signing lhiv forts, I hemby certify that the ireli(vt was(iver4)ahandnned ire
County Parcel W14:1504tJanN0.(PtN) aownlance with d i.4 XCAC 02C.0100.or 2C.0200 TtJell Conslntction Stariikrrzls
and dart a cggt,of dlds record Im been provided to lha wall onver.
5b.1.ititude and longitude in degreesfmdm itcafseconds or decimal-degrees:
(Ifnvelt raW,oa4l;iiliong to sia;:C A) 9.Site diagram or additional well deta ll_v:
You tuay use die back of this page to provide additional uell site details or well
N W abaudonntent details. You may also attach additional pales if rsecessuy.
CONSTRUCTION OF WELL(S)BEING ABANDONED SITBNWrrAL TNSTRUCTiONS
ttirrdr bell cxl2Ylri,Cti+Ir!ralcvn$r�r 1J'at�tilreGlt. Fw'multipfr rr�ctirur w rnun-u�rtar xuppll
titIIR ONLY 9i'llh dine SV.Vi CYDctf17k11L1�''ArJ[LtdliUlydleYJt,I Jtl Cpfi_SlrLritlr U1tBJrJrltt 10a: For All Wells Submit this form within 30 days of completion of uxll
61L`VCK E 1#.Al-A16 abandonment to the follatI.,ikw.
DdpiAnn of Water Resources,Information Pruces_cinr Unit,
6b.Total well depth.: 14 (D,) 1617 Mail Sci-vice Center,Raleigh,NC 27699 4617
10h.C r Tnl pion Wells: In addition to sending thefornr to the address dt) 10a
6c.Borehole diameter.2.25 �n.) above,Am submit one Copy of this fora tvilltiit 30 days of completion of%V11
abandonment to the following:
Division of Water Resources,%Underground Irij�ctdou Control Program.
6t1,Water Icvcl below'ground surface: 00 1636[%fail Service Center•,Ralci.gh,NC 27699-1636
6c.Outer casing length(if known)-. 00 lac 'nr Water Sunoly&Tulcetlon 3Ye11o: In addition to sending the font to
the addresses) above. also submil one copy of this form within 30 days of
completion of well abandonment to the county hicalth dcparmwnt of the county
Gf.Inner cilsinWtnbing CenlKh(if 6morvn): (ft.)
where ibgndoncd,
ft Scrmn length(If known): M.)
Fenn MI-30 Nonh Carolina Dep3naxnt of Environment aril Natural Resoumcs—Division of Waver M-oimes Revised Augiru 2013