Iredell_Well Abandonment_ (2)

WELL ABANDONMENT RECORD Forlmcrttal Use ONLY-
Tdlis fusty taro be used Of siltnle Of utetlliplya wells
1.Well Contractor infortuatiott: WELL AMN_Q TNMEN'r DETAiI_5
Robert Miller 7a.Number of lis being abandoned
trt 1
Well Comimietnr N"an!e der tcell awpef Perhom y ttlm%douinr%Loll chid hivitia[irapem r r'v irrtrlrtni� trt at.totr cc� rntrt-rrirtea i d9!.tr wells ONLYr!h th nut+e
c'attLii?wStdf�+lx75rurrii39a![�!f.S,•tN,�Rt ittivaiiP etc.fnr.il
2675 ?y,Approvmate volume of tvater semaining in yell(%)F/A tgaLl
NC'iR�etl�snncac+rCcnifualinn Natn:hcr
SAEDACCO Inc &­.k V r—Uv
Cantprtny N tr!w lc.Type of disinki1ant used:
bff+ rllflppproGltu 4lperitiud.c.(;varh SZutRlurturr:.Lrf-ec4ini;cfrrilX=+��iy Id..tiu6tlntefdbinfectxantu%t.d' Irt7;ii'+'."3'{,`�1 �(i !^.y3_lln�!
3.Well use(cbeci:vrcll rose):
Water Supple'%Veil:
t7ts4tmici[xtlr 7e Scaling tnatcrials usctf(:clierfi all that apply):
❑A ric 1 1 'Ptiiilic;
Ncat Cem tsnn
ent ot 0 Bcnionitc Chips or Pcllcta
g n tarn ❑DIV Clsv
5a Cerrtent Gtviit
❑(.`rcnlltenrcll S;Hcatin��Costbn�vnpPty) ❑R�,i�f:tttanl Water�uttpl}(ainGte) ❑ � .
:r
❑IndmorillComniercial ❑ltcrtidential Waler buppic'(,stmed) ❑►-'onctcte Grout
❑lltilt Ctiuiri
❑Ittia tion ❑Sgxia[ty Grout ❑Gravel
i (ia-%Vatcr 4upph•Well; M Belvottite Slaril ri odwr(eNplahi tuder 7g)
iujoction Well, X.For each material ariccted above.provide amount of mrttcrials used:
❑Agttlisr Rectiarge ❑Grptuxi'udr 161wdia ion
❑Agnifer Starage and Recovery ❑Salinity Barrier
❑Agviferl'est ❑Stmm�waterDtaitu-20 Bentonite.:751b Wtr:7ga1.,
❑ExTeritnettial Tevintulogy ❑Subsidence Control 7g.Provide a brki'dL.scriptipu of the abandamttcnt procc+iurc:
iJGeottlernial Wlosed l oopt i3Tracer
Pour from surface.
G1G.aotltemtat iT3e ttiOa Caolinit Retumi 00ther hc. lain under ZA;
d.Date wctl(s):tbandoned: 5-27-2022
;a.Well location:
Trane
r=WtyXhvncrN n-, Rr.iifty TD4 draPR -lizablc? .Ccrtifka[ion:
800 Beaty St. Davidson, NC 28036 _ 5/31/2022
Pltysical.Addrevs.City.end Zip Si_K>�a;:n!"i:F e.t� >9 :::'>. ir'^y'°sr+an r Dim!
Iredell By st„aare ,thiv bunt. 1 lrelvh'e rt�,11tr11fs lvelltvi was prerrx abase oned in
Comm ftrel 1J.-Ha6wliuu No,4111 tl arrohlim r.wilk 114 bC•[i_"CtX.0100 or 2C,0200 it e'11��j.ov ie•oon Styr(har fs
emd dral za copy r_+J thfs recce ci lun pert►prtrr irl.ii ro Me tr ll olTne.r.
Sb.t,•arimdc and tmr�ntude in ctctrr+cesftninutrsl5rcnntls or d�itnal dcgt�e,4;
tt1 nett rxtd,nits l itilt!it rc ratr;csctai 9.Site diagram or additional well detalls:
You twky me the back of this page to ptovide additional well Site d tails or well
N W abarxlaur erd detaiV. You tuay also attach addititnull pdgg s if ry cessat4.
CCINSTRIIC'nON Dt'rAlLN OF%V1rL1 .Sa BEiNG ABANDONED nLf ATiT A t,W-TRRCTiQYS
;#trod tr!'cr_mstra�£rnr.n.cvr•lrit tr'urvt4a�:i. l�u�tmrPtm a itdxsti:�r ry rrnnrvlrr xrl+lri:
a eldr UVLi u arjr r e a,uta srtra..a_t urt al+untk+!;:arrtr qua cprt�rtbttrit ncrr ti me 10a. For All t%tclls: Subunit tlrit form tsitWu 0 days of eorttpletiun of vic11
6a.Well Ill9:
MW-16 -ib tndountenl lu tie:foilntying:
Division of%aatcr Resources,Information ProcLssin;t Unit,
1617 NW Senicc Center.Raleigh,NC 27699-1617
6b.T0talwctl dcptlt: 40' (.ft.)
106.itirr T is th4lt%arils; In addition to af'ndinge 1W fann to the addrm in [Oa
above.also fAdintit one copy ©f"this form N%itlrihi A days of completion df%%ell
(c.Borehole dlnnutcr;2" (in.l ab uulaunieru to the fallowirt4:
Dlvisiortof%VaterRmurc6,Underground Ltjection Control Program.
6d.Water level below Found surface: tft.) 1636 Mail S¢nice Center,Raleigh.NC 2 7 69 9-1 636
30' Alit,`..Fnr Water.Satnn1v& role tfnn Wrelta: In addition la sr.ndin^die form to
6c Outer eosin.M Icngtlt of lat►tvnl: Fft 1 the addFess(es) above. also subn* .one COPY of this f0tni Uilbin 30 days of
ccrupte(itin of wet!obandoitmem to the county lrcm[ttt deparintettr ot"the rautay
iyh�re abin,�lar�d•
61.latter casin hubin„+teap'th(if lamAvn): Vw
6g.Screen leagtb(if Idtmr11):10
Fnnri G�V-air NOitty Caroline Depcsrnucm of ftwoiirnant m'd Aituml Resumes-Di+Lstin of�b'ute!r Ri uurces Re iced Atipus.200,