MO-27707_47024_CA_WSW_20200601_Well Abandoment Record

D.L. Mullis Well Drilling, Inc.
PO Box 1338
Monroe, NC 28111
Ph. 704-226-8802
Bill To
KAREN MCMANIMEN
4429 WOODWIND ST
CHARLOTTE, NC 28213
Invoice
Date Invoice #
5/23/2020 104008

WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
1.1�1e11 ontractar �o]rmaliau:
L—r�Jr J � �! C4 ✓
Well Contractor Dame (or well owner personally abandoning well on hiAer property)
NC Well Contractor Certification Number
D(_ W uLt).s
Company Name
2. Well Construction Permit s#: e 0x)1 ZP3
List all applicable h ell pernats (i e. County, Slate, 1°areance. lnjedion, etc) ifktroirn
3. Well use (check well use):
Water Supply i} ell:
❑Agricultural
❑Municipal/Public
❑Geothermal (1-leatingjCooling Supply)
V estdintial Water Supply (single)
❑Industrial/Commercial
❑Residential Water Supply (shared)
Mr-rigalion
Non -Water Supply Well --
❑Monitoring
❑Recovery
Injection Well:
OAquifer Recharge
❑Groundwater Remediation
❑Aquifer Storage and Recovery
ClSalinitySarricr
❑Aquifer Test
❑Stonnuater Drainage
❑Experimental Technology
❑Subsidence Control
❑Geothermal (Closed Loop)
OTracer
CiGeothermal (Fleatin_gVCooling Return)
❑Other (explain under7s)
4. Date well(s) abandoned: � II I Z_'6L C
For internal Use ONLY:
WELL ABANDONMENT DETAILS
Ia. Number of wells being abandoned:
For mrdliple injection or ao11-crater supple
con.Fiructlotr.•`abattdoamenl, you can submit oneforur_
1
wells ONLY iprih rite same
�
7b. Approximate volume ofwater remaining in well(s): 2 ^U (gal.)
FOR' VATER SUPPLY WELLS ONLY::
7c. Type of disinfectant used: t
7d. Amount of disinfectant used; __.
7e. Sealing materials used (check all that apply):
❑ Neat Cement jout ❑ Bentonite Chips or Pellets
D Sand Cement Grout ❑ Dry Clay
e Grout p Drill Cuttings
13 Specialty Grout ❑ Gravel
Q Bentonite Slurry ❑ Other (explain under 7g)
7E For each material selected above, provide amount of materials used:
S
7g_ Provide a brief description of the abandonment procedure:
C2) - f,,
So. Weli location, ) J
1�Qr to F ol14
Facility/Owner Name Facility MA! (ifapplicehle) S. Certif tt u:
`'jl V (l L JO 7tl v. r" cJ S . �iir lQ (' A/C 71
L
Physical Address, City, and Zip Signature o Ce fied Well danu2etor or Well Owner
Cody Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field. one ladlong is suihcient)
WP) lzozo
Date
By signing this form, I hereby certify that the well(s) isms (werej abandoned in
accordance with I5A NCAC 02C.0100 or 2C _0200 Well Consiniction Standards
and that a copy of this record has beets provided to the well outset;
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS) REDIG ABti' DONTEU SUBMITTAL INSTRUCTIONS
Afrach tr-ell caralruction recard(s) if mailable_ For multiple ulec11017 Or itaa-}rater srtpply
u dis 0XLY o•idr the came cousirtretion abat id 8
utmren r , YOU cmr su err one j mi.
62. titi ell IDn:
6b. Total well depth: _ S 0 (�' (ft.)
6c. Borehole diameter:
6d. Water level below ground surface: S b (ft.)
10a. For All 'Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699 I617
10b. For Injection Wells: In -addition to sending the fours to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636.
6e Dater casing length (if known). _ j[�p� (ft) 10c, For Water Supply &_ injection Wells: 1n addition to sending the form to
the address(es) above, also submit one cop} of this form within 30 days of
completion of well abandonment to the county health department of the county
6L Inner casing/tubing length (if known): _ ' i (ft.)
where abandoned.
6g. Screen length (if known):
Fenn GW-A North Carolina Department of Environment and Natural Resources —Division oCAVaaer Resources Revised August?013

Beverly, Trudy
From: Bob Payne <[e-mail]>
Sent: Monday, June 1, 2020 6:43 PM
To: Beverly, Trudy
Subject: [External] FW: McManimen-Emberland well abandonment
Attachments: Invoice & Well Abandonment(2).pdf
External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
[e-mail]
Hello Trudy. This site should now qualify as Low Risk. Thank you,
Robert A. Payne, L. G.
(cell) 336-684-2734
Cedar Roc
EhIVW NMENTAL
Jeremiah 9:23-24
From: kemberland
Sent: Monday, June 1, 2020 6:20 PM
To: [e-mail]
Subject: McManimen-Emberland well abandonment
Attn: Robert Payne
4429 Woodwind St. Charlotte NC
Please confirm you received this record and can go forward with paperwork.
Sent from my T-Mobile 4G LTE Device