Iredell_Well Abandonment_20240910 (3)

WELL ABANDONMENT RECORD Far lrscnOVseONLY
11lus form can be used for single or multiple wells
1.Wen Unerrartnr Infornution: WELL ABANDONMENT DETAILS
Scott Hunt, Jr 7a.Number of wells being abandoned: 1
Well C'ottmctor Nime fill well o%sim 1wruijully alunkninF well on his,lrr propens i Fnr w0rapk tnietvton or rww-"Y#er srrppA wrifs (ANLY with nk• sraurr
cvttatfrttt'ftuw OhnlnhMMeW.1rIM trin a'YiNn/l tntlr frlrvn
4561A
NC Well('ats#ndor Cenlficntnn Nnnbn
7b.Approximate volume of water remaining he wellla?: (R+fl l
SAEDACCO FOR WATER 111PPI,Y WELUSONI Y:
C'onpftm Name 7c.'fN pe of disinfectant used:
2.Well Coast.tine a Permit iM r ,
IIJ,di�Nrrtiltr/AICNY/1peMnlXn.1.C�1MIM' Ume.Iarldwe 1tw'I it.etr.•ifA!n�N --
7d.Amount of disinfietaut mud:
3.Well use(chn-1:Hell use):
Water Supph Well: 7r.Sealing materials aced(check all that apple):
UAllimultural ❑Mamicipal:Public ® Ncal C'cmeni Groat[ ❑ Hciaonite Chips or Pellets
Mkothcrmil(NcanrksVCooling tiuppk I ❑Rcsidertial Water Sttpph rsinglcl ❑ Said C•entrru Grout ❑ Dn Clay
❑lidusm:il,'Comnicrcial ❑Rcsidcritial Water 5ripph isharod) ❑COMMCIC Grout ❑ Drill Cuttings
❑Im^nun ❑ Specialh Grout ❑Graiel
Non-Water Supph Well: U Berdonite Slum (A Other(explain under 7g)
i N10111tonng ❑Recos.en
lajw•tinn 'ell: IN For each material selected alime finnide anumat of taterials used:
❑AquderRecharge ❑GroundwaierRentedimion Neat Cem. :941b ,Wtr:5 gal]-ongalSand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Reco%rn ❑Saloon Damcr
Bentonite.:5�lb ,Wtr:gal.
❑Agader Test ❑Stomra;uer urainigc -- -- -------._...
❑Eytertmental Technolog\ ❑SubsukttY Control 7g•Pr N itk a brief dcscriptinn"f the ubanthinnicut prnarlure:
❑Geothzrowl(Closed Loopi ❑Tracer
pvc removed; grout borehole from bottom up
UGeothenraal lHeaUn +Conlin Rchanl t IOthcr Its am wdc�r 7 1 — -
J.Date'A011%i Abandoned: 8-23-24
Sa.Rcll location: V n 202A
Statesville Dollar Tree +i
EK"it MN lk R,CrrtilicaNtat: �: � i• Y
la. 7C+Kt�F 11'"•^3M•.'y �n
2189 Old Mountain Rd. Statesville, NC 28625 8/26/2024
1.
Ph+sical Address.Cwy.and Zip xi•rrc ill'!c RA,A Wen Ce awtot to Well 0%ner DOW
Iredell A .rigntng thts fart", I hereby ccrfAf that the w•eU(ri was(were,abnrirhnicd lit
C'otiia� Pared Idertlficatriu No.tPINI ac•rorrk#ac a wtlh 114 XrAC 0:C.0100 or:C.O.VO F(WI C onstruc non bAandrm/r
and thaf a crrpi of iffrr record hm•beer#prrn tderl to the well turner.
5b,Latitude and lonKitudc in d gilveslminuteslscennds or deciwl dqpvm
Orwell fold One bula"t i.,ullicwiti t 9.Site diagram or additional well details:
You nim "be tine back of this page to prcnide additional well site details or well
N W' abandonnieru derails. You roan also attach additional pages if niecessan
CONSTRI(TION DIJAILi OF W E LIASI BEING ABANDONED S(1BMiTTAL MSTRUC'TIONS,
Ailikh eels coartnrc101I1 mair.EV{i atwhr4k. hw mnfollk oyea non w rwn-itaur sy�•
wridrONLY wl#h rhe.w,mcwr..nvrrNor rtnwnh,rnwrr,t)ox can sot nit soil hHn#. Ilia. For All Wcib: Submit thes firm within +0 da%s of completion Of will
6a.Well IDf•TMi"l-2
ab;nidonnicni in ncc folknring
Di%isimn of Water Resources,Information Prucrodun Unit.
6b,Total well depth: 90 1617!trail Senice('enter,Raleigh.NC 276"-1617
Ift.i
lob. For loleclion Wells: in addil"i to sending live form to the address in Ilia
rr.Biirrlirile diameter:2 :tbutc. abo subrim otic cm of this form ssmhm ui alms of completion of well
tin.) abandonnicnt to the following
Dhi%ion of Water Rv%ources,Urider•grvuad Injection Con Irll Program.
6d.W'ah r kill hi-him rrvuud wrfaec: 30 (ft.l 16.30 Mail Service Center,Ralcigh.N('276"-1636
Irk.For Water Sutw)h & Injtction Wells: in addition to sending the form to
6r.Outer casing length Oif(mow n c (D•1 the addfess(esi abo%c. Asu submit one cope of this fornt within ill da%s of
completion of well ;abandonment to the couta} hnith dcparimcni of the castiin
25 wlicrc atxandoncd
o(.Inncrcasingtubinglen•ah.ifknnwni: (ft.l
6g,tierce"ICngth rif I,now"c 15 (h.l
FOmi GW-3n NonACatulou lkwnnriv of Fro rmnnaid:lid N:auml ite.ourmes-Dii tstoa Of w'stcr RC50uWvs Re%EM Aupi9 44 t