Iredell_Well Abandonment_20220627 (2)

WELL ABANDONMENT RECORD rartcd:rn;llt tJN1 Y: 1
This ftrttn oft be used for MIT*or tnulli}�F�tells
1.Well Contractor information �L'FLL A$pyDf)NAIEN C DETAILS
Robert Miller 7a,Number ofivclL%beitt};sh.mdoued: 1
a r r l
1 qr neldrtple rog4ra ar or 4kw-11Yltt'1' FklltAt�• drlLs t7;VL}' rtth tit st:ne
'1t Cpl�I:rs'r6r tti:ip�tar tt�ll 174iTif t:Cru5lt:dlf 1l);rnlArlus�:sell eh his:Lti. p'u4�n3. r , ra -ip.sUlwttr ia1�it1nr
Wt, rvyrs:mrc�tt!a•s�s»fiR1rt:�rat.ti.rt�u 1
2675
?b•Approximate Ininmc of water trinaining in Wtll(s)?� A igrl.}
NC t4alfl C��1rtctor rcrtitic;flints Karol&t
FOR WATF.RSUPFI.YWFUS0,NI.Y:
SAEDACCO Inc
C3nv;UvY Nantc 7c.Type of disinfectant used:
2.Well Construction Permit 6s pp�
l t a'efli a," It'll t2rrt0j&il.a+.t irartlY,Sloe,1 i rwtw,hyly 4iutt etc.i if&hawn 7il.a�nloltn[of tliaiufeetaat USIYI' — E 6�5�F� � d
n:-..use): i
3.Well use(check troll J U N 2 drp
.2022
hater Supply well.: 7c.Sc;tltag taatcrials uccd{check:Atlt:tt altplg):
❑A�rr nittaml ❑htuniLiptltPttb6ic Ll Nutt Ccntcut Gantt 0 Retitttnitc Chi pr.,Qc(I Until
❑Gcotlicnual(Hcalin.1 C1 Moling Supply) ❑itz�idwnrial Water Supplt(single) ❑Sand Cement Grant ❑Di Ctay' DI r;QI BOG
❑ludustriall onvucicial ❑Residential NYatcr SupP4(sharMl} ❑Concrete Grout ❑Drill Cullings
❑hti a•tiou ❑.Sp,cialty Grout ❑ Gravel
Non-Water Supply Well: is Bentonite Slum, 0(Jute?(c--plalu under 7g)
Mhfunitaring ❑l L oNeny
?t:For each material sleeted above,prntnide amount of rtarterials used:
Injection Well:
❑Agtaer ReLlur a ❑Gnsundwxiier Reu:ediininu _ -
❑Aquifer Stom,"c anJ Recovery ❑Salinity Baffler
Bentonite.:501b ,Wtr:7ga1.
❑At}trikr Test ❑Storumnier Drainage
❑l:ap:rimeival Techuotoer ❑Subsidence Coatttal 7P,.Provide a brief description of the abandonment pntcedure.:
L"7 odwrotal(Cfoscd L.00p) OTracer Pour from surface.
�lGcttzhemral(Id'nzi0 'Coaling Relutn} L`3Gdt<r ts. lain utszler 7t;)
:1,Date welE(:!)abandoned: 5-27-2022
5a.Well location:
Trane
r';�:frty:� hvm'•rN.� r'ac City 1DM(ifatlpii;ab1c) S.Certification.
800 Beaty St. Davidson, NC 28036 5/31/2022
,allot Addta�s.City,20 Zip Vic?LaU:: _.t .' Da;c
Plt qr
Iredell ltt'siguer(g rlus frtrm. 1 helvi%v cart ft'riru lix nrell(s) was tifetei ahr wkwed in
t�natti }�lrcet hlsru4r 1tttluNa tfat\) actcv Mier mlllt It 1 V(..4 WC',0100 or?C".O.M117(fete'C:uersiniciAnt S7rnlrfitfth
and 11Mat a cop,of tiers recartl uuv beet?Pilo ided io the well enswer.
5b,Latitude and l000tude in degmesl'minute-slsmondsordecimal degrr:es:
(ifna:urleW,01a 9.Site diagraw or additional well details:
You may ase ilia back of tltis page to provide a�dditic otrl well sits de[aits or well
N W abandouruentdetails. You m2y u w unaelt additoual InaMS if tr crssan°.
(`ONr+7ftilC-ffON D TAILS OF tyVFI.,L(S)RVI N(.ABANDONED S�UBIlfiTTA iN54TitITCTiO�15
Mad?wV0 ewrayLatclQsv fran-d v it uvWhAilt. Mw nadhPle ijdeaimi rAr own-irutlr.>rllfpti'
irlh ONLY?rids rtu+wvtc c rue•fiN.rtO.r sa mroi5trracmr i:rt rat,:srl?mt a rr,unit 10a. For:fill ♦VeM Submit this farm uvinn-'0 days of completion of ur11
ai�andanntcru to tllc fnilaw'ins;.
6a.Well I1)#:MN-8
Itiviiion of Water Resourr4s,Information Procemanb Unit,
1617 Mail Service Center.Raleigh,NC 2"t699-1617
6U.Tutat argil depth: 281 (ft•}
10h.poor I lceliort WO -- In addition to s,ttding the fora to the address in 10a
above.also sitbirtit arse copy of this form withbi 30 clays of completion of well
tw•Borehole diameter.2" (in.} abandonment to the fallouirt;:
Dhislun of Water Resources,Underground Injection Control Ptugram,
lid.VL'ater tcvd below gtnund surf icc: {ft•) t636 Dfail Service Center.Raleigh,NC 27699-1636
le' Me,Ear Wale► Szznn }tFcctin rfta: in additaou to sending,the¢erne 14
6e.Outer easing length(if known): (tt•) the address(es) above. also Submit one copy Of this foutt within 30 days of
completion of well abandanment to the cOtmty heathy dsparmicru of the zounly
whore ib u:amd:
6f.InnercasinPltuhing tenttth(if knotvrr): (ft.)
6g.Screca length(if Im01va):101 00
rams GW-Sn of Miter:te;oulsx-S ,hllcust 20l"+