Caldwell_Well Abandonment_20240205

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IVELL ABANDONMENT RECORD f\C-6Q-4' For loknul Use ONLY:. ' •
Ilis form can be 4ed.fer•sintle or tutlitipleWells.
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11,Weil Contractor Information. \ - . •
WELL A RA NDONNIENT.DETAILS
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. . Robert Miller . . 7a.Number of wells being,abandonf.141;1. - •
weir 63„i,-,:ii,f-tsrat,i ( r„,ai,3,,,40,sr4i.,:tly atibmaning ucji.an hisii4r 0.60,,y) • For thippk- thfectian or ,linter .supP.1), 'wells-. OYLF with Ilk
awistrtichonlithairitohineht,'vire ph,s7thnik:?iwitwitt,
- . . 2675A . • , . .
tz:T.,.7.7.ifl.:.1:7-.3'-,•,,, i gm.:r-s),. .7b..APprniitnate.,nbante of Watt*rein:aintn--g in ivell(s): • - • , ,. . (,,.ial.)
NeWal ConitactortoittlionNomber - • .
1,,,;.t V ft— '..i..../
SAEDACCO . .• 01t wxripR$UPPLYWELL5 ONLY: . ..
. eompati•Nant ' • • • - -- 0 5 2024
7e.Type of:disinfectant.tised: • .
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2.Well.Constructlan Pernik#:„ -• Int..r7---..Ai'l,•-) Prr.,(7.-.„511W4i141 Ufa • . .
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•Lut 0Tplietthie well isaw:01.!-'h.e..aelary,Slid i!.Pardifrre://i1V..6yek,;:tyller1
' .7.dAntount of didnfet tant'used:
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3.:Welt.use(ehrdOvell use):. .
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• - . . Water Snpply well.-- • - • • . . . . , ,76..Sealing matedals:used(check all that apply): • • . •
•EIA.grEcultittal • lj&ttinidipai/Publid: - - 121 Neat Cement(hoot - • , El Bentonite Chipsor Eti:4t-. .,.
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13.Geothemral(Heatingtooling Stipply)- -, 13lIcsidential Water Simply(single) P.sand;Cnnt Gr91J1 . : .El My Cla 3' .. , .
.11 COnereMGrout . .r • ' : .0 DOB'CalliMIS ' •. - . Olndastrial/Commemial• - . , •• 13Residential Water Bupply-(ilaired).. •
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0Inigation. • • . - . - . . 0 SPeeial' tY,Grout • , . ' • 13 Gravel , •• . . .
Non-Water Supply W.e11:" ' ' -. .0 Bentonite Slimy . ' 0 Other(explain-ander 7g)
• . 12Monitorine. V 1312e ty cove . . . . . • . , .
• . Injection Well; • . • • -. •- 7f,For cacti giatcrial aelcetcd'above,proido amount if titatetials used: - -
ElArMiferltecharge . . .-OGrOuridwaterRentediation Neat gem;:471b ,ritr:6gal.! Sand Cern::lb_ ,Ntr:gal. .
liAquiter StomgeairdOedoVexy •.liSalinitv Barrier
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.. 13Annifer Test . . - - 13SIOnnamtcrDrainage - . . - - ' -. • • . ,I . ' - - . . -
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• 0B.Iterintental Ieclmotoev. . .PSubsidence donttol. 7g.Provide a brief d4scripihin Of the abaritin omit pruceduret •
DGenthettnal.(cfose4 Loop) 0Tracer .. .
. Tremie grout from the bottom up
. 0Geothermat(Heating/Cabli .ng Reiuml dOther(m-ulain under 7n) . . .
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4.Daie weuw.abantbincth 01/192024 . . •
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5:r.Well[oration: ' - - .. . • - ----- •-• - -- - - • -
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Caldwell County Landfill . ... . . • - - ..• - . . . .
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Facility/OnnerNiunc • • . Facility Mg(if-applicable) 8 0Ceillflention: ' . • - .
. 280,0 cheraw Rd. .Lenciir,.NC.28645 . " " V . • '-1/21./2024 "
pliysical'Addrcis„•City,and Zip • • • .sigton.:V.0t‘;!::•r, T.
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. Caldwell - . . • - -By sigaingiNs farm;/hereby cerafj...'Mai'the ireNsi was(ware)abandoned•in
County .• ' - - . -Parcel lderitifiaitinit No.(PIN) ' aux:adore With 15.4.-NC4C,02e.01001,orc?C:0200 Well Catisti-udion StandaMI. • '
- " - •• 'aid.Shwa copy of this-record',kW ba'61 provided(Ore well owner:
Sb Latitude and longitude In degreestininittei/Scionds.ordetirmr1degreest • '. . . . :: .i . •
• • (ir*oll rteld,obe tat/long tssonkion) V . • 9.,Site diagram or additional well details:. • •
. .• You.tnay use theba of this page to provide additional-Well site details or well '& .
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• W .ahatidonnient details;You may aLSo aitaehaskiitional Pages if itteessalY.:
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CONSTRECTION.DETAILS OF WELIUS1 BEING ABANDONED• ,StIBMITTAI.INSTRUCTIONS 1. V. . .
• • Attach ti*11 ativitritetiati retards)if diiiildite. •Fur multiple ePeillail 0)-Mus-u•utile 54.01.
• . • wei4 ONth.1010 sono'cAY•gmcliGg'''bthg-Alftjle4-m41 COO Slijintifi:"0-1"*- : '7 10a.,Fo r All-Wells:• Submit-this&nit within 30 days:of.eompletion•of well . .
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abandonment tothe•following: •,'- -
.6a.wit i-D4iP2-104C . . • .
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• . . BiVis in n of Water ResatirciInformation-PruceAng Unit,
• • .6b Totalwell depth: 8' 3 (6 .I6t7 Mail Service Ce4tcr;Raleigh,NC.27094617 • - -
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10b.For•Titlertion Wells: In addition:to sending the form to the address In Oa
abate 'Asa-submit one tom.;of Illii.foith within 30 dirYS ii.f.'camidetion of well
6e.Borehole dianteter:2 ' (CO ' 'abandonment lathe following: 's I
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• Divisionof Water ResOure ,:iluilerground'Wallin!fault-IAA/vagrant,
.6d.Water rad.bctow ground Sll rfa c e: - . 0.0 .. - 1636 Mail Service Ceitter,Raleigh.NC 27699-1636 • -
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. . 1(1c.'For Witter.Sunni,.&Iiii0tion Wells:. In addition tci sending the form to -
Gr..Outer=dug letWdr(if larown):. 74-1 ' 00 the address(es) triboVe also submitE one eopy of-this fomt within 30 days of
• . completion•at well abandonment tol'the,(-county health department of the county .. . .
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• whcrc abandoned. ' '
6f.Inner easing/tubing Length Of[mown): • - • 0.)
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• 6g.Semen length(if knono):1° - • (lt.) . . .i .
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Faun GW-30 •. -Navin C3E011113 Departmem af'Ssaimontent and Nthwal Resimmes—OhisfonorWatzrucsoarpos •Ir.aviacd AnEnol 20E3 • •
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'WELL ABAND.ONI IEN.T RECORD Forin1ctnal•UscONLY:. ' ,
This form can be used for.single or.nitilliple Wells • •
I,Well'Caotractvr,Informatiotu• WELL ABANDONMENT DETAILS
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Robert'Miller . . . 7i,Number of wells henj abandanadi 1
\VcIFCoriactorNaate(orn llowrsIj tsmrunyala f_ %It!.afillisli rtitgic ir:i for. nrirTph� r,tferrrar; w•' rmn-�itiiw• supjiIy wefts' ONLY •'terra ilk. .srinie
4 ,7f c.rrrrcraai..bon.d...y..ciot sillmat ie nn,
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7b.Arpmiitnite svtlume of rat&remaining in Walks): - (u)NC Wcll Conttactor crtiNoit Nnnbct0 Fro5 2024 i,. i.
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FORWAEERSUPPLYWEL1SONLY:• .
SAEDACCO UhOrit,::;ao.i ?:. 3? :g Un • I:
CanpunyNamc
l'iWCI'BOG lc.Type o f diidnfc'ctrnt used: . •
2.`4Vcll:Constructioit Permit#i r• , ' '
Lis!.Jl npptkvble.uxll parmiis fie.Cinh'•,Srete ariurne:Ihfrctinr;,Nhi) t misrt • - • " Id;Amotm• t of disinfectant used , -
3.Well usr(chcckn'ell use): ' ' •
Water Supply Well; • • • • ,e.Seating materials:tiscd(check allthit Appiy); : .
- IJAgriculttttat • phltinicip il/Publhc, III Neat Cemetit:Gtvat- 0 Berioriite Chips or Pelle s,. .
[].Geothermal(Hcating/Cooling'Su ikru ppty) . pilesiinl WaterSupply(singgle) ElSand:Centent Groot ❑Dry Clay .
❑Ittdustrial/Comntereiat plicsidential Water Supply(shared) ElCouciete.Grout j -U Drill Cuttings .: . '
• ' -17ittieirtion - . - : .b Specialty Grout Calcal' . '.
Non WatcrSupply Veil; ❑B•entotliteSlutty ❑`Oiler(ex• plain tinder7g)
piMotiltoting . , lRecoven' . . .
Injection Welt: 71.Foreach material scicetcd•above,Onside autogtit,of:nuitesiats aced:
• OAgnkrRecharfe ❑Gtotti;nivaicrRentedinlion Neat•Cem.:471b. ,Wti:6gal.I , Sand Cem.:lb. ,Wtr:gal.
1]A4.181terStonigdqui12ecoiien! 0Salinitp13anier• . l'
❑AgniferTest . UStonimuterDtairiage • •
•• ❑E'cperimetiial Technotoev • ' USubsidette Control • 7g.Provide a brief description of the ab.i ulontncnt Pmt clnre: • •
❑Geothemnl(ClosedL Loop) . ' ❑Tracer I' j V
Tremie grout from the bottom up .
- .❑Geotheiniat(Iieating,CoalingReturn) bather,(explain udder 7g) •
4.Datewei (s)abandoned: 01/192024• . • •
5a.Well location: • - . - -
Caldwell County,Landfill . . •
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. FaeilityithrnerMovn Facility ID#(ii'appli:ablc) 13.CCrtlfieation:
' , 2800:Cheraw Rd. _Lenoir, NC.28645 . . . .' • ' •1/21/2024
Physical'Addres:City.ani Zip - - - Sipreli: 4,fj,;t:;.r.: loci i^e4;::! -,.',.':mg. .Dato
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Caldwell By signing-dais fariai f heieby certify'drat the u•ell(s)tiros(tcerwt abandoned_in
touoty .• • - Pnee1hieniltacatlnallo,(PINj . 'arurrdance*LerIiA:\C11(02C.0It10.or2C:0200 Welt CaiisliatctianStrinihtitls '
'and that a copy of this record lies been prowled to theWell onlier.••
56.•4titudcand longitude in ttcgiccslmtaulcstsccitnds'ardccttnal degrees
await valid,one Wong.a Stifiirecnl) 9..Site diagram or additional well detarts:
You tuay use the back'of this page io provide additional well site details.or well
N • W .abaudotituetd-details..You may also attach additional pages if oecessan'- .
' .CO(NSTRIrrrIOY.DETAII S Oil WELLS)BEING ABANDONED• SUBMITFAI.INSTRUCTIONS I'
:meth n:cdl cnrolrnetieit ritnrdls)if available. For multiple 0terfiotr or tins unto,aspph' '
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meQs ONLYiruli the svute rwrsbraecion'o reicatf icnat,)ao eau arhinii are Aria. 10a:For All-Wells: Submit this form within 30 days.of completion of wall
Ga.1,VeD ID3:Pz-73c • abandonment to'tIi fvllotiving:
• DItisian of Water Resutnrcis,Information,Proctssing Ididt,
41.4 1617 Mail Service Center;Raleigh,NC 27699-1617
Gb..Total:�fell depth: (n.) •
Oh.For In'action Wells: hi addition to sending the fonts to the address in Lila
6c.Borehole diantetet:2 pie.} above,also submit one Copy of this,fond within 30 days of eantptetion of Will
obuudamnent lathe fallowing;
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Divisiat of Water Resourets;Uudergmund Injection CoutrulProgram,
6d.Water inscl.bcltm•glornd surface:. (ft.) 1636 Mail Scrsicc'Ci;ntcr,Raleigh,NC 27659-1636
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6c.:0uter cabin tflai0nzt•• 31.4 10c.FnrWntcr•Suiinlr&Injection Wells:'In addition'td.sendiug the form to ' '
fi ten ( ) (t ) tlte,address(ls) above, also submit:bite copy of tires forth within 30 days of •
completion-of well abandonment t the county health depaimteat of the county
• 6f.Inner'easing/tubing length of known): (ft.) where;tG tndon¢d.
6g.Screen length(If Imown):i0 . (ft)
Fort GWV-30 Nonh Caroler Depcutrucol of Ent•iroaatcat and Niuumt Rcsoiures-Dh ision of Water Rmouins Revised August 2013