Iredell_Well Abandonment_ (4)

WELL ABANDONMENT RECORD For lrncmail5c.ONLY:
This form can he used for sing.13 ornruJliple rtells
1.Well Contractor Information: WELL ABAND0,V&TRNT DETAILS
Robert Miller 7a.'Vumber of well%[icing abandon-W 1
1Vdl C:olnlacter N:rattc(or",all ower peMi nth ab.1w1 Ling%eu am 110111a:r prepzrk}) f xr r zrhir-lr welt; ONLY with Ilk) s wle
C!rf.:•rfll{'r:ill fIS!1dSiV1171ilYdkrJ�YYfid 4tnt 4L111�1).!P fit!IE�r�I:
2675
7b.Approximate volume of water mmaining,in veeli(.r'1 A (;att•i
NC"1w1Cv nr�ciorCGrlithtion NutrbaK Foie�y� WATER ti�r
■ ^' `�'i"�
sUPPLYrf•Ii-s ONIL : Ft,.C—_ LL...s _.
SAEDACCO Inc
C•ougan)imams 7e.Type of disiaieftant used:
2.Well Construction Permit lk �. -
'itali lcyihletrePd,txriritYfr.,.e�.,tn S.•.a;Joni,rc.•.littxucn,c�tcr1,f,t'm�:rr In,-Grrty�'i.nPMZ=CJii riff
7d.Amount of tlisinfectant use�ii:
v
i 3.`Yeti use(ch►wi:vv'ell use):
3.Well
ter use(C'ed- 7e,Sealing inateti:ds Peed(check all that apply):
©Agriridtur 5l f7lvltinicipsdfirtllvli Ct Ttr:tt Gcnieut Crotty a Flctrtonitc Chips or Pcllct3
�C,ciitltcttri�l-(Hc�titsr}i4aolitic atpply} 0R4:z lentiai Watcr vuppEy(single) ❑Sand Cement Grant ❑ Una Clay
❑htdusari+IdC omntcrciai ❑Rs it@entinl%VM;:r Siipph•tsitamd) 17 Concrete Grout ❑DO Cuttings
t7Ttti Lion ❑Specialty Grout 13 Ganes[
gnu-1Ynicr Stipple Weft: 0 Bcnioti to Slurry L'1 t)thef(ex-pltain tnWer 7g)
Mmonilormg MRawwr
tojcction Nell: 7f For each material seicctcd above,provide amount Of tilatcrials used:
Mgrufer Recharge 1,Gmundiv-:arr Rcowthation
❑Aquiter Stunige alxi Recov t* ❑Salinity Barrier
v . t7rau�t Bentonite.:50]b ,Wtr:7ga1.
I7AR uitea Tesi 17Startriv at� tv
`
nExTenutetual Tochnology ❑Subsidewe:Control 7M Provide a brief description of the abandnumcat pnrcedum
riGeotlletltiai(Closed Loop) tiTiacer
Pour from surface.
®Gcotllettilutl iticrilim Coolie lianirn) rjot eriospiairtundcr 7irJ
d.ilw,rtc ii'cil(3).ahan/lane[[: 5-27-2022 -
5a.Weil location:
Trane
Cacilits,, %wr Wom: raciIIt;•IRH(lfappti�vrtvJ R.Certification:
800 Beaty St. Davidson, NC 28036 5/31/2022
Plt+sisal.Addr ,City.and Zf}i1L7Y7Ilf: ':.'•;::•:'•:°�' '�7�"ter D.
Iredell 13v.laf:nrl�g flits}f-imi, 1 hemby cord'v that d1L we.'Irs)vl•,rs rlrerei ahmifloned n.
emonly fla-M lde titilt anan No.(PIN't aieronlancs mill[1.),-1:4CiiC O1C.01OO yr 2( :O 00 lFull f_"timm-w-0 r)r-la hoards
mid!tint as copy o filiis reeurel[firs beer[provdded to dote troll enr'r:ea
Sb,L;tdwde-and long tudc in degmesfiralnutestsecondsordMinal degems:
(if iven raltl,oil 1 lrrltrn i afll ti) 9.Site diagram or additional wdl details:
on tirav use Like back of this page to lizovide atddtti(!wd well Site dewilS or viell
It W a ibandatimetudemils. You tua}aist�:tsiacilsnlriitec+intlpages ifix"Vssaty-
C fHSC CIt11C"i I{)N DETAILS OF1YELI(4)11>IN(:ARAND()NED ST3Ti14tiTTAL tNSTRTiCTTQYS
:i wrk.ivo Lwav,rceidrur mcmko iJ,moida5di ourrrnrlGpl r,ticrtMlir rri rlxr=unrrr-,zq i•
neliv U.16Y tr;[1i rlx•njunetrur,rrtrri,r;r cs::v ch.lrr.:erar>tau coif=ubrr,+t cam isr;; IUd. For All }4'etl� S»hmit this lam[ vvithin sU days of campiction of yell
Ga `4cU.tU :NSW-18 ab tnllonmcnt to the following:
Division of grater Resources,fafotrmation Processing Unit,
6b.Total iteit depth: 24' (ft.) 1617 MAScrvice Center,Raleigh.NC 21699-I617,
IUti.Tor iniecditinAVON, in addition to sendiug the fotni to ft address in Iba
alcove,also snbritit one:copy of.this form vvidtiu:1(i clays of complelion at well
tic.Borehole dianietcr:2" lin.) aba ndauinrn to Cite fallowing:
CoL Water level batnn gnmind surf ace• (ft.) Division of Water Resources.Underground injection Control PM-ram.
I6dfi Mail Senicc Ccntcr,Raleigh.Iv('21699-163b
ter Fib t{r�lei Surin1v&ln +ln MIN:
to a ddition to scndiag Ilia font to
&..0incrc:rsiugicngth lif kaovrn): 14` eft.► the addrm(es)above. also sulitllit One COPY of this loon Witbin 30 d;kys of
epmptcti0u or iaeil nbantnmixnf to the comNy hcaith depannicni or des cotimy
wh rc Ib n doncd,
(of.Innercasiotjtubing tenl,4h(if(mown): m)
6g.Semen leng4h(if knonn.):10! [slit.)
Pone fete°-.11) Nonh Camlar,Def nmcm ofEmJronti«.x ttW Natumi A:si nreas-t31 islori er W'a[et Itti ancr3 tie,tSLd Aitgum'2110