Stanly_Well Abandonment_20231229 (4)

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NVELL ABANDONMENT RECORD Fat Ida'nudOwONLY:.
° 'ltis fo'fui:gii be us�l_ftir sl>1Rf;r or intdliple.�fclls � ;
-i.,Well,ctint6twt.lnrotritittion:. WELL AVANAUNNIEN`f DE:'IAL X
Brian Ewing 7a,Number of nclla being aliund I and.1
Weirtarrtw' ,'r, n"tW,or:u`lI iir p:rzai tl uii fii A4r'prulieng) ra' rrarFnpf0 PlAltttar a+• mra yat& 'supply tfaNs VNILY Wth Avy --swite
c4tisttircfxxilmhrucimuu,*rrt;)nrtcxnr?jh, rtu,
4240-B
7h.rlpprnximate niniitc of Frrltu'mmainink in well(N) (dial)
]VC1VellConiti�clorCeitifzwtiuu�Nnnf�ar 1. ,
SAEDACCO l*OR WA'ri~1t.SUPPI.VWK.m;C►NLYc
CauzPnni'Nautc' 7e,Ttyle�,if,disinrie6ilit 6se'd:.
3:Wclt Cot>;etvefiop.Pcrnilt tl:
ld3fir{i.rrttlhtrOk;utifltaru'vity ti.aCyLrths Srrrt•►artiirrc .liJctttrlrc.rte p.ifdt,uwrr: ;
. ?th amount of,dlsIufrctaut lisivl:,•
W tur Supply Welh. 3c:'Sealing mate",P Iis+iil(ci�¢cl:;ail thtit uppiyj;`.
17r1;maitttcii, phttipiicrpflll'tlbtic., dNcittcmtcmd:.Crluiit• Ci ScntQaitcC.hiRsorl'cllets;,
C7C)c4iltenn►l(Hcatity'f~p nlitk;Supply) Dttcsi mitt[�'Vaker Splrply'(siq�ic) D Suiid Centeitl ardut 0•Dty CL),"
❑hldusltiaL'CoitmtciCinP I7RmideMitC%V:tter$ulSAiy'(sltatixl) d,CQndtete'Gte�ut _C1lt{ll_Ciitiin
t[Tni tion [].Specialty Giuuf [T Grdi el
Kira V!"otrr:5u lit}:�VcE€: l�.Bentonite Slu ubikw(evviain utxier 7gl
�l�fanitoditg:.. �Ittxp�•ety ;
Tajcctirn Wcll: X For each inatcrlal selected uboce,pros ide aimoaiit-atittatudals used:
I]elgnlferLterfuttt,+e . OGttiuiidi►;fteiltentecli:ftioii' Neat Cem. 971b. ,Wtr•3ga1. Sand Cem, lb ,Wtr gal.
CIA Sionise;itxt ltecot my ❑Salinity Barrio
❑r�quffc�r Test ❑$tiienri�'aterl]nifti�gd,: -
Ll&w.tiuteu6nl tbtih oloff O§ubsidepo Cbittml 7g-Pr Mde u liri di�crintinri pf fire uininilpumcnt peruciyluttr,
bGrolhen,irtt(Cioseti.Loop) rjTlcer.
TREMIE GROUT FROM BOTTOM TO SURFACE
dGeodwritxiltB ltimirXpotinaRetomY C30dwrie.� lainutider7pJ
It r r-s
a.liati,�tcU(i ia"64nd4ncd: 12-1-23 L_ t• lJ
DEC.well Gleu(iiitip 2,9
Residential Property in rir,>ni2ri i�r^^•Stir.+;T?F�URY
Caciiit7�+tiierNnnui F�cil'�'111�"'iEa Ii�6lcl $:.CertiQeliail: .
DtrliQi'30C
28384 NC-73 Albemarle, NC 28001 B dq n 'win 12/7/2023
Phy5icalAdd>m:Citp,'�lZip S[i*mveroii1triedNvatcallukijicF.,;'411('11v a Vim
Stanly 652801490612 &sj�at{g thiv;iirui, !ltemby,eertrfy,r/ma the willfs)wax Awe Uf1AAtlrAdJrtl'!7i
t'aiiis[j' 1'4rccl tih^.iU3l"o�1I1n1i Nn„iPtl�} ricevi•tlttl:cc frrllr 15.1�4�+1G`�ZC fI1.fTd ur 3C_02pO T6idl Cwfa�hitrfiari:Stfncktrcts
mtrlllrirl;rtcaps aflhfsrecordhityhaeirprovirered:iai'lre.t+e1!tiyiier.
Sh-Utiftide'and.loogltude I dcgiv6hiltnt tcslscinlids ar dixim;'*degiecs..
(ifl4ellF4t4I;i),u4itritmp3ssrittie lx) 9.Site dingramoraddltlaual well detatis:
-you may-use t&bade bf this Pa' pro}•ide additional tF�il Mk-6 ails:af well
35.3638555 , 11 269.4 80. 093., abaudolnneultleta[Is`S'OU[m0}''u1Sti�`7LLLtt It adillt[Oiial[XI+ S if IYEt t'SSUty+_
Q tb1�SfRllC'C10N.UF TAt➢_S O '*ELUStij89iNG ARANQQNk0 SURM11TAL iATSTRIiMQNS
.:Itlrelr hell eur..ti•!1ltrli+Lt nctvflsl'tJ�Oiilalfiatik. 'F•iiu•peufnpir rirf'rttlrL:,or'rmr,•v�rur siflFtPj' .
Weidsl7AI wall tw,smrntcarstrracttGtt iafiiiirthi>Y11i tt.�rte cnn sir5iiri!�>Jrt frlim. YQa:Niir All t &N, SUht12i1.1biti famt'tiitt»ii 30.dny'S aP canitttetion of tticll
6y, Yell ID �rlW_2 abstndonmcitt to ttic'follaain;: '
Elt6lsian.of R'utcr Resqutt�,InfurtnutiouPrucesri.n�Dnit
6h:Totalitell depth: 40 IN, '1:617 blairSmice Cedtc-,kaieigb IBC l-7699-1617
ft.I'a r TWmtlm W 41s: In odditiou to seuding the fgrnt to rite aildttss[u l0a
tea 6c�rcltole.dlan+ctcrt2 du;y s►bo�ti:ufso snbntit.otte tupti,of Iliis•farm tcitlitit 30 diiyS u1 Cottfptzi[ou of tell
ounietu 16 the,falia1t•in.
IDEvisloti.gF Wutr Rcsoitt�c�;.Uaeder,rimtud �� u Coitltvl Pre
641,WaterteF0,betait•ground aieraccs (ft7 1636 R1 ti1 Scnice Ittiter,Ralciphi NC:27 t[o 629-1636 igt•iitu,
fir Dow casingtetmoh(If latotrn): ( ) 90c,l±ae Venter-Sunnle aCc-inlertif, R'elia;. Im addition to semdimg the form.to
tile:5ddeessfesl :ibai;e, also sntimil,one copy of t[liS fotut with :10 days of
coniplctian-aett-elf atiatrdmrtncnt to ilic county Ireitfth-depiirinicid u[the couuig
6r.Tuner eitsin+ itihin'.tulip(if tatown): (ft.)
tt'licr>r a(xlndoiicil.
j
Gd:Screen leugtlt"([f kuatt n):20 ( )
Pilm ml-t0 Nonh Cara[lin QcpcnUfi of of Entiouautcnt atal N:uutat RcsawTcs-Qh is€an of Vlatcrllisoivas Reviscd -Vsi 2bt3,

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NVELL.AI ANDONNIEN.T RECORD faitdgm- Us> ONLY !
' 'this foiui can be'used-foc.single or mttllipt�.iF�11s 4
t.VVeER tititr;ICtite,fpfoetilution: W LL A8A,NjD tiNhlF-NT DrTAff-;
Brian Ewing 7u.Nutnberafrv(llibeirigullwd
�Yelt etuaCILeh'�nre:(otu tlus�usrp t sirially,ti( sitfosrin;i+�ll61t,hrslltcr'prp}icfly) �a rr+irl//rslc Uyutiom 91 rmri nir �rrpix� wrlfs 'O,t`LF with thin' .sa+re
c?+isfrrrcftaa'm'+iurdnnma#.:arirr cvr VAIN rlt`aie�lrh
4240-B �.-.�
NC1Vo11C6a1raaurCottillcaliuuNtiirrSM 711,Alilik6ktnatetoliihevfvr.+tu t letitlwnj in�iell�a)z t1;+t4S
SAEDACCO FOR N%'ATFRs.1urrixuI~. sO.N'`LV..
Conaanti Nantc:
7c�Ty'ge liP dlsinfi�itunt u3eil:
2.,Wett Consttuctioo Permit 4.
113t crll u r, ttabfe ii�tl jarirriiti(ism Ci rrr+tj',SFi1 ,,Ydi Jilrti�.IlrJrs�fU17,;N1f 1 fRlNrvtt 7d;Amottnt of,disinfcctaut ukd.:
3.r1VdL ul�e(drat] iVcll."'W):
Water;supph,Wellr 3c:Scalitag�ti wt1 .ediitls tiss+l fcliGcl:'aii that apply):'
E]Ar tilturiR l7hittni¢ipa tt7Pttlllip• E�,Nail Ccmciit.Ci[tsist ; �! �entai ite cho qr mllets..
C 0mlltcamhl(HcatinpJ polIitg Supply) j]ItcSidotnial Wufce a'(illni}'(iri�lo) �Sand Qlku 15ltiut ! O Dtt Clay
17UtdnsttiallCgmmctcial ❑RWden(l;xl%Voter SuFFIy'(shattd?: b,Conct>ie'Grout E1 Dal1 utlings
01rtt •tion 1],'Specealtq.G out l7 Grdte1
-No!-Wor it cr.SupLe Wc t1; 0 ElentoniEe•Slut'tY 7.gj
}g11416191odng:_ i71Recovery-
rnjcction WGII:. X boor.caeh utaterpal selected above9 provide atuonnt of-utatenals itsed:
ClAgrtiferltecbais, C7Grci uidtialer Rentcili:iiioii: Neat Cem.:471b ,Wtr•3g'al. Sand Cem.•lb ,Wtr:gal. ,
I7AtjnifeeSiunlr!e tirYl itee�l•ei}� l7Suludti�.[larrler: .
❑A4pifer Test r2poinilvater Drdiiitrgn
OEyteiitttentoi Titltuoliag} I7Sulasidr tier Gitiiml Provide a brief di-scripttiari of ttic-ril►aeedanmcat plroeivlurm.
15Geothenirdt(Oioscd Loop) Mincer.
TREMIE GROUT FROM BOTTOM TO SURFACE
®Geothounal(HcIEp&ccoH Retunt) 00ther W-Nolain under 7tti.
12-1-23 y°
�.ilrittC 6FCll(5).abi1rod011Et1S _
utc
�tl.�`feti Lneali/110: .
Residential Property to , ;iLtl eft Cam' "a
Certllic;itiviec .
FacilitgtshsircrTi;utic rxiltlVLne(IEapnlirablcj Dw'r�tt'�it7C2
28384 NC-73 Albemarle, NC 280.01 r1."a�1_ _E-�r f i!i ]2/7/2023
Plt}sical'Addt ;Ci{�,'aridZigo SiiltlltrndfC ni�iCdtV4.0i�tr4fo?'w atfhrdr Dim
Stanly 682801490612
If,V Fdfa7:ll1tify lf+LS jFtrrrt,.I!rein&,y:eri'Prfy,'Jhnt tfae u•Ei11(:aJ ti-rrs orgre)m5rtrrdorted nt -
Cdriut'p t rrCl laitrl3fiv^itln'it Nu.(PlW ctuv►Yfnttcc a itlt f S;1.4 1G 112L',t7f0(t:or 3C..02[t0 Fell Ccuialrucfiurl Sfiirithrrrls
' �rtrrd•llri3l,u cnpi�ofdhis r•eevrd lvu b�e+a f+iroviu'cdta llre.uefl ciu'iier.
-. :SU:.I ltitudcattd.i.�ttfiiturtf�in:ttey7i�iiltittcsls4�rtnds.at•deciituii clegtecs: '
(it d kit E�4t;Herz ptU►ond:is stritic0.raj 9.Site diigrvnlur ad6lbu,tt v♦ell demUs:
You Ala}ttse flee bacl:bf tilts page to}itov ide additiQaal null site.details,tar vv 11
35.3638555 , N -80.2609493. ��• abatniotnueuttfetads. Youtua}aLsattt]CltacklitionalpEtge
siftleceSan
Q'rDNCTR UMON.IlETAlll_R-OF t4'ELL(41 BElNr:ABANDONED SLIA4tT1TAL iNSTlt11CTON's
,.-trtadf 16 d cr„rslnietiW+riiyritl;l'3�rairiJl !tL 1'ru ueulNpfr r+r riielh,rir r�nn•�rxrtu grip •'
swilfQhPLY:triitrtLm.son rrn+rstm'r.rtrr+rhd,wrJ61 tin cmrt:iwrrepravrT.mre'twre.1 fin U.' ga;p;.lar-All WcUs.- SOml.t ilkis-rnrnt tiithitt 30,t3tt}5 of catupidion of~tell
(Dt#•.
Former Smith MW-1 abindtittmcittta tltc folbtivia
6a.�4ciC
6tviskil of Water. R soutcq s,lnformati+in•prucosim,Unit;-
1617 Airiitsen•ice Ccntcr RalciWi,NC.27699-1617
6U.Total hell deptU: 39 (ft) '
110b.Tot•fnleetlatn t6clls: In odditibn to seudiago the:form to the address in 1Qa
6c:Rttt !tole dlautetcr:2 aliave;also subui t.otte MON.ortlii form ttithiit 30 days or comoletiou of iwil
�h') ab;i6dtintttcni to tite•fallo}tiu�r!
Gtt,tWatar aeq� (ft:1 bkitislau.pf Wutet•Rcstitrei•s iTudergtvuiid Iuj}�`tlou C/intrill Pceibrnm,
i 63f 5tail'�t`icC ecri ir,Rglci;b;NC 27699 1636"
Gc..Uutcvca5ingtere h.(afflmoirnj: (ft9 14c Tnt•W eCer 9113111c A tiilmligro t-r11i: In addition to kndittg the faun.io
the 5ddmss(es) aboki. also suliatit.que cope of this tbau «it(iitt 34 dap of
coniptctian of tv�ell aliattdattni:nt to tlic wttrlt}•Itcaltlirdepattintersi of iltc eourt;ti�
tvbrty atxtndoncd,
6r rnmeecusin ltuhlug tcnjKlt(if Lmo n): (ft)
6g,scremn lengfil(if lmotln):'15 (ft,)
Fann Gt`r-34 Nonh taro[!m Dcp nrtkat ar!}lttclmontcot atal N ttursE Rcsuuzcs-QJs isioa of Vratu Riss�itt�s itn•isni AuguM 2011