Union_Well Abandonment_ (5)

WELL ABANDONMENT RECORD For hotel Use ONLY
This fonn can be used fm single or multiple wells
1.'if ell fnntracmr Infnnnstim WELL ABANDONMENT DETAR_ti
John Eisenman 7s,Number dnella beiaL•Abandoned: )
Well(bnracxs Nam I.,allow...pers nvlh;annlopn"wcL on Aa tar proppm, P., mxlgpi. ..q,✓.... - n,l i with the xW
4439
-b. Appnninurt ,alit mrd waterrMlyininLm.rllnp NC Well Caamnnr fcniFcalion NOOK, Igal.)
SAEDACCO Inc FOR K'ATER SLPPIA KELL40NLV:
cow",Nam 7t.Type ofdislafman sad:na
2.Well Ceeatm-tiun Pernk C.
Laatlynprkablr ueH;rrm,n.,,•.4'wm,.4ae.liwtmwe ltg.wdtx ek nam.. 71L Anawant of dbinfectanl used:na
3.Wed net Oheek WEN aa:R
Water Suppy Well: 7e.Staling mAtersal%uvd icheck all that algrh 1:
❑Agecuhaml ❑Municipal:Albic W Neal Cement Camu ❑ Betaonste Chips nr Ftllct%
n(kothcrind f Hcanng Cooling Stlpph'I ORss,deraml Water Supph Ismglel n Sand C'enlor Gwut ❑ Dr,Cie,
❑hdri%nnl:(OHIMCM131 CResdertial Welter Supph l shared) 13Concrete Grout ❑ Doll Corona
Obligation ❑ Specialh Grout ❑ Cimrel
NrWalor Supply Well: ❑ Benlmlite Slum I Other lespi;nn wdcl 'v
®Mooifortog oRamen_
Injection Well: 7f.For each mateial elected above.prw%file anmunf of mytertah uvd:
❑Aquifer Recharge D(Gromdw3ter Rcineduuorl Neat Cem.:94lb ,Wtr:79a1. Sand Cem. :lb ,Wtr:gal.
❑Aquila Storage aid Rom m ❑Salmis Darncr
❑Aquil Teal ❑Slomnwalcr Dmrmice
CEtpeneuaal Terhaoloh ❑Subrallcre C crawl
7g.Preside a brill dexrslwioe of the ahaedlmnwnt pnwsduro:
OGoothental)Closed Lmp) CTractr
11Geolhemal MentingtCooling Return) uOthermliban under 7 r well abandoned in place_tremie portland from bottom of well
to surface.
f.Date we0(%)shAmlmedl 10-31-22i.�L i V jam •.'
Sa.%ell location: NOV 2 R ?n?2
Hills Cleaners
Facihr.Owsr Nemc Fxda,IDxwfaMileabk) S.Cardresilee: Irtte;ra::;:a ;�r..;:,✓ae.J Ur,:.
� a'dQ'SOG
1305 Skyway Dr, !tonne, NC 28110 --- 22/13/2022
Pin seal AtNwne.Can.and 2p
Onion !iv.egpugQ dRr��.f:w-:�._,,.h,thin the well(m rr was rwet.Ib,mJ.uwJ to
Cotmn I'm,,]hfmdeanm No IPINI txxnnhwux wilts IM AUACO2C 0100or 2C 0100Well(swkrlN.han.V.mtlfml.
tm i lMa a mpf o/Ifris renrrd hoe beer,prrn-rtkd m fie wet/owner
Slk I.Aftillde and Inngitude in dcWvtarmlautrvu cnnd.nr decirnsl degroev
t if.e0 feld ;arc Ian.hen_n.onrcunl 9.Site diagram or additional well detaRa:
You rtcw lee lire back of this page to prow de additional uto eke details or wall
N K' abadennleta details 1 miles, also iawh adebtartlal page%if tln:essiln.
CONSTRUCHON Ill:'I All OF N i I I )! Bf IN(, wD XNI)OSED SUHMMAl.INSTRUCTIONS
.orb 0%1.1 „n„, ._ Ilia. For All WeSs: SlLrmt this limn within ;0 dins of completion of well
6,Nell IDa:t4W-4 Wi dcnmcru la the folimung
Dirt.ton of Hater R"o rem.Inl'urensthm Prucnking(.'lit.
611.Teed well depth: 43 111.1 1611 Mail Senice(Center,Raleigh,h('27,61.r-1617
Mb. For Inleetlon Willa: Io addiiwo to xtdneg die force to the address to Ina
abrwe_ :dw shins it one cop} of dos fonn wwtlan ill Jaws of completion of well
M.Ikm•Iwlk•Aianen•r:2 Iin.I 36311donencN Ili the Inllmvuse
Dn Won or Water Rexnlrc..,(nderynxlnd Injection(oalrul Pnptraa,
bd.%%Ater knell born. ground.uriurc: 14 Ift.) 1636 Mail Senice('enter.Raleigh.NC 27699-16.M
fire. For Water Suddc 6 Inkvlkrn Kelly In addition to sending the form to
tK.Ouror cavuglmgth of)moil nr na Iftl
Ili :ddresstesl chow e. alw %ablelrl one eup% of INS form within to dasa of
compkrmn of well 3bandi nrtem to the comm) health depanmerit of the co11T-
bf.Innarcysing'tulring k whttcAmtdotednLth lie knoanr: na Iftl
6%.Sencn length Iif Mow n ena Ifl)
Form GW-Ai Nnnn C'aobr Dc)unuwn of En.wm,wn AN N:ouml Rcsauc.s Dh amsd Watt Rewnes Itc, A Auguu 201 s