Catawba_Well Abandonment_20231228 (2)

NVELL ABANDONMENT RECORD FoTIni malUscONLY:
This formcan be use for sitggle ornudlipfe wells
I.Well Contractor Information: WELL ARANDC)N&IEN'I'DETAILS i
Stefan Smith 7a.Nrimber4%vdIsbeiu;;aband6nl 1 1
0'ettConitaetorNatne{onc¢llnnn�7p an�lly �amtnnivg��vlloaLigll>crptapctay) For nigluple hyedtaT or ma-vaferP supptp wells ONLY wab rile .sane
cmufrrrcoi •4zbmrdoirm�grt,yr�n cror,mbriilf nri,�jbrm-
3576A j
71t.Aliprnzimatc rulmiaenfnotu e+imarintmg in gell(s
NC�tdfContrddorCe�ili(`icaUonNnnitcr �
sAEDACCo FOR 1VA'1'mSUPPLYwrtuSONLY:
Company Name' .
_ 7c Tyitc iifdisinfectant naed:0
2.Nell Caustruction Permit 0:,
Li f 441 well parmiiV(t.ec C ante,,Srck,d'arl4wi.Infergato eta)Pfk wwn 1d.Amount of disinfedlint used:
3:tvdl use(etiecl:s�•eu tarej: - ,
Water.Sttpp4v Well; 7.Seallrtfi materials tiscd(chcci.all tli tt appiVP
171gricnitirrat piolunicipa Public, ❑N&t Ccnicnt.Grout t3 Hcntonitc Chips orttllcts
gCccotliCrmal(Flcatinr�fC:ootina Supply) 17ttcsidtr0LjI%Vatcr Sjfpp4-(singic} -G.S nd:Cement Gmut t7 Dry Clay
❑lndti50611cott aimi,4- ❑Itcsideat4d%Vatcr S:pply:(stiacd) t1 Concrete Grout ;Cl Dfilt alai gs
❑irci tiau Q Specialty`Groul 13 Gravel
Non-%ter Betdoaite Slum 0°Other(explain.under7gl
❑mo iitodng. l3Recovery
inicction FVcu: 7R For each t»ater ial scictted aboF'e,provide antoutit of luAtedats tt5sxl:
LlAgWfer Rcchnrl;e. I7Gmuiidttaler RenQWiuu
nrlquiferStontgeatrlRmgv l7Saliiii Ranier
i3AgttiferTest P]Stonmvatu.Dnt(riaac 3/8" Bentonite chips Amoimt:4:i
p@speriniental Terlmotogv ❑Subsidettcc Cotrirul.
7g Fen%idc a Brief dercripdon of tlic aliandnnmcnt procWut.m
OGeothern al(Closci Loop) OTtacer
POURED CHIPS IN 10" LIETS AND HYDRATED..
®Geathertttat(Fieadna toolin Return) NOther(c.Mainunder7g) LJ
. _
4.Date,*CU(s).abandanccF: 12-14-23
$a.-Well tocatfon:
Marshall Steam Station lnkrjgL7; n Pfoctlftlr
Facility/t7ten rNnmc Fad by mm(,rappikabic) $�Certittrition: � UAk
8320 NC-150 Terrell,' NC.28673 12/19/2023
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�,a -
Phys al-Addms.City:and Zip S ihmgr<ifwxl Nell Chi*=aror 1V41t 0-n%-r Darr
Catawba By ai f:ing this farm,1 hemby certify dltht Me irell(s)was(were}abandoned ire
Couuiy Pamel fik:o ft:lltiatt No.(PIN)' acxrtttTitnce WXYMAINVAC_02C.0100.or 2C.0200 if%e11"Constradlan&anAnis
'mid fkit,a copi,af(Irls record Iran•been pnwided(o.the we11 darter.
5b.iatitudt andlongitucfe;ineteggceAliulaiittcvJscrnodsocdccihTol'degrees:
- (tftsellft<;tct,Oise boii gissnfmi^ae} 9.;Sitediagr inoradditlonatwcildecafs:
35.59859 80:.964427 You ahly use the ba&oftllis pgge[oprodide additional will site:details.or Well
N' N .abaudoiuttuddedrits..Vou loop A► aninchudiiitiomfpates if uecessan'_
C6NSiTRIfCPIOY-DFTAEt_C OF WELLS)BEINC:ABANDONED SUBMI-1717AT.iNSTRUCTiOMS
:fth=t ueff rOMAx LWOU nivrd(s)'Ij'ai4ollwla0. I2u•m111hp10 6gecdon'tr mn-uwlW•wpplp
mils f?NCI irfUr can lunrr, t0a:For All'•�Vcltc: Submit•[his form uitldn 30 day5 of minpletiuu of uelt
6a.4VC11 ID1I'SVE-2
abandoumcitt to the F0110,,viag;
Dirisitinof Alaterl2csoarecs,information PrPan4ag Unit,
6b.Total tF'cil depth: 10 (n.
1617 ill: I Seiviee Center;Ratciiti NC 276994617
f,
fob.F04 inleetinn Wells: to addition to sending tl>r fotnt tp the address In Ma
6c:lior hole ditsutctca:l above.Aso-subtrut otie eopz;of this!foiin widiiii 30'days of comptetioa of ur.It
ubiiridounieut to the folltitt�i -
.. i
glvislnn pf\Ester Resouecs,Undcrgrrtund 6n jcton Central Pnigrani,
G&waterlcrel,bclon ground wrfaec.0 ffQ•) 1:636 MA Service G i ter Raleigh,NC 2789-1636
6n Outer CLOng1610h(if Lmown,): ( 10c'FieMterSurinh•&iiIMIL"m��q�; Inaddidonto sending the fomt'm
tile-5ddreWes) above, also subnitibue copy of tins totrtt within 30 days of
canipletiati of��rtt abamdoiunent to;thc county heatth depailmeM off the county
6L Inner c.rind/tubfn. tcn th cif lmawn): (ft)
%vhcrc atiandoncd,.
60'.Screen length(If knots):
Fami GAI-10 Nonll Camfim tktwuneua ofEnvironutcnt and Natural Resoumes-Divisianof WararRcs I umes Rwi,cd Aqua 20t3
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