Iredell_Well Abandonment_20221208

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For Wemal tlsc ONLY:
1•"lVcltCtint�c�r.Iuformatimi: : 1 ,
/V}�•` ( � 1 �VEI 1 A ifApllll�AlMEi�Y1 ETAl1S
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f G` 7a..t'or GeoprobdDP-t or Closer]oop Geotltehbal Wells having,tho snipe
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fi"r ""a tOf�vcit°« t orally nixusdantng-welt on Fdslder properly) %yell eonslruetion 4th,only 1 GW-30 is needed..tndicote TOTAL Nt M HR of
,G, ,7 Milsnbandonede
1�Tc well CUnareen9fimtioa tvani�r '
.�' / 7b-tlplxiAeiete volume orwater mEmalsiiAg In weil(i;)s
AI 1rOR WA fER S1JIRLY WELLS ONLY.
Cozy Nemc
2..`VQp 7e-Construttion Permit#• 2 a Z Z.--1 a 3,6
Type of dtsiufectant used; 10
T.lat 4!T ripp) Q6la"�ioUconslrudimrpermttt(La Ut4 Cougrys Stafa Vnrtipifcc M)1fb 0µ4 ] "
3•SVell use(check'iveirese): f7d.Amount ofdlsinfeefantused:
Water:Sukily Well:
7e•Seating matcdals used(check all.that Apply).
11Agricuitutel OMumcipaypublic
1]Geothential 13 NeatCcmentaMd O-Bmtmite:Chips or pellets
{HeatiAOCoolingSupptp) Oitesidential Water Supply(sitigtd) p SandCeinetttGtout
tlndustaayCouunerciai L7Rcsidentiai Water S 1 sha" 3 Dry Clay.
C►lri etion upF Y( > tConcrcte'G;out 0 Drill Cuttings"
NOA-WafLrSUp�Jy"WEII: p soccwtor0lll I' O r7lFntll__
❑Monitoring .. URaaovcty 0 Bentonite slurry-- — A Otber(cxplain"undo 78)
la9ectloa�Ve11:
U-Tor each waterlAl selected nhoVcl provide atnoantArtilAtertais used:
pAquifer ItecUargo :L1Gro�md►yata�Itemettintion
QAguifer Storagis�and Recovery tnSeih»tyBairiei
L7Aguifoi Test bstormwattr Draibage-
p»PerimentaiTecfinoIogy t7SubsidcneeConuol
t7Gcotitennal,(Cltued I cop) M"cef 7&Tr"Ide n brief damiptlon of thenlrandotimenf'proeeduree
ClGeothermal(HeatiAg/Coolin itetwn`. L]Other`" lAitturnter74a14
.
4:Date well0 abandoned; ,
5s.Well location;
•fir C .0 202Z
FaaLtylQtvaaName
r� D `"Frae7apvpmFtttfapplkablje) i4:.CertitGatlon: • Initrl:3i�;�� ?1. .:=y,,,:ng 1(nw
!- r ► \ © /N l r 4 p�/7 C YS `�/%� '/J
I ,Ghtjr;ead gyp SiBoisture eFCatlfied Well C�onCac4or of Y4eitORver / •�
�1 b3�—n z1-Z3w7
co°ab' Pme3ldeLtiscauauNo.(1'1lt) rhlsl thereby e+ rijy liuu`lhe,e{a7f(s).was )abandoned in
ac h&fiwwith`ISANNC#X,O,�o&2C.#Mjr,*Convinu dlenSlartdmds
b&JAUtUde And longitude in;degc&/mioptes/MmJsor decimaldWecs: ajwrhbrar0OfthbMmId/n prayf&dra the.wfl
(ifwdl Geid,-om laihongia suwtci t).
9 Site diagram or ltddltldaal xc3i details;.
lY W You May tt aAw.back of thts'pago.to provide edditioaal WeD9te details or well
abeAdoiimeat d;huls You.may also attecb additioAal pages ifs,,
CONSTR (!TION ABTA 1 bB WL�I LfSi Bf fNG AAMQM)
Alfodrwtllawuhrrcponrocortl(a)rjmwlabfe,•Formulliple s
ONU%*hl1rs®ie:cautrurtt`on/a6apdnnntnU y�m(amfubmlionejorm
4A i0a.For"-An Ift: Submit this
6a.We11 tlDke fam itlun 30 days.of tonopletion of weU.
.
u6Andaitm�tto the followitrg ,
Ilirldon of Water Restiutcea,Wotmaaou_Ptocrssl�'Unit
Pi Total iv2U dtpftis, :.((t,) 1d17 Miiil3eTvlce Ctnter,RdtklPi NC 276*1617
/J 10b.For iinleefioA Wetly'In Addition to s6adiag tho_form-to the address in 100
di—,Hore6oledietneter. to j above,:also:submit one toy of this form wit(wi 30 days of completion•of-well
ebandonmeattotbefI Owing: i
6d.Water level below ground snttaatr,,,,;,�,d7 �) Divleloo of Water Reso I t)®aergrouna rttJecfton Couhol Pro�im,
50
� i6�i6Mai1 Service Cijntert:I6,NC2'l699.1636
6e.Oditer caging lengfL ii'j -J tB,) 10e.�or�yAter 3unn�v 6c Ipjggt(on"Wei� 7u additiatt.to sending the farm to"the•
ndilress(w)sboVo,also subwt we copy of this form vIthin 30 days.of completioA..
of tell Elan oiunedit fo,ute county health depattmcut of,the.00tutiy Where.
6LTnnercaafw-ftbicglength(itiworyn): (n,) a6andotud
Pp{m GWV-30 NasIL Grutinal)eoxuaea►offiitivimnmenat cwurm,.nl+:,,....cw..:.o...:. ._