Davie_Well Abandonment_

WELL ABANDONMENT RECORD For trrletp7t 1 s 10t4ifl-:
Tttis fount wi be wed for•:singie of ntuttiptc Wells
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t.Well Gontincfir►islif"nation: AMU ABANgC)NMEN'T DF-TA'tt:5
Robert Miller To.Number of well'shelft abanddtted: l-
Wdl Cotirtmaor Naw(or welt aui►it Kmwlll}ali4 woniq Ncb aft 1ik9rbr propms) ten' rotdaple 1g,�Vroo w swl-0rder stq", >Ai fls ONLY wtfi rise ;,Ole
- r�xsrracr,ru,�at,�r�rtntrwtr,,ir,a�m►,�,lu,inr.�tr firnt`
2675-A
11►.Apprmimate Volume of wahcrrtcmaining,in wc'll(s): (gist.)
NC Wcbl Corti nooir Cbniauroon Nil 1143
SAEDACCO Inc FOR`SYATrR,$UPPI YN%1F j-$ONLV-
Con►lian+-KAIK 7c.TV c rlt ili�nfcrtant ttsed:calcium h p ypchlorite
2.Wdl ConstrtictiolfPermit W: ,
Uv oft3ra,ldkable vwIl tuitit.-k 6-e.(7-juntj•.ShN.1"4rT&et-.brie ria,r,ifi i f f d'rrAkrr
7d.Amount of disinfeciant tisc'tt:'1oz
3..Well u.e(chlt:"n"ell utic)t
Water.Sttpptly W'cll: 7r»Scaling mit4'niij ow (Abel,all that A�tp11):
bAgirkidiuraf GlhitmiCipalfittblir ; Neat Ccmctit Grout C►acnittrutc chipS of Pellets:
OGrnfhenn al O)tcsidcrttml tVAtcr Strppt}(ingtc) O SaW fC Drat Grout t]i3rt't"' v
OlWff.nt(bYCotnmc(c lit OlteSidendat Wrltci'Supph• sh:tW) O Coiltretc Grout r3 Dsill Cilttit
E11rri 'tion O Specialty Gwilt, O Grbcrl
Non-11'atcr Tttispl,iYcli: IJ Beolo►titc Slum• CJ Other'(explain utider 7g)
smonitoring bRtcoveTV
lnjcerion,W41-. 7f.For each.rtatierial osctected'Ahot'c,provide anmi nt of-mHtct+its nsrd
OAquiferliech9tgc, 17Grduiidiratcrtttti'tedidi6n Neat Cem.:184lb ,Wtr:12gal. Sand Cem.:lb ,Wtr:gal.
OAqu►Err Storagt atttl ftc�Yn`er�� pSAhnii}f3amcr
OAttttifet'oet OSinnmcattrDiathwIgo Hentonite. :31b ,Wtr:gal.
OE\*petim:ntal T icltiioiugs ❑Subsidence Coutiti! 7 ►�ttiiiiic tt lrtis dcsct iptitm of`the ahf ndttntncnt rrl►ceduc:
t]Gfnllrernlsrl(Ctoscd hoop) ♦=iTrtcet.
Trimi from bottom to It ;�^•-� -..,c
{�Gaothem�rl(Newlin 'Cooling Rdum) ao ttzrtes lain aiid cr?,) -g
7 �6
4.Disk 0,01(s)abandoned.: 11-2-2022 NOV 1 g 2022
5a.W"ell hwation {n,'c� '>:-��"t3 Unit
Walgreens
Pxcilitylf►wtts r Narrie Facility iDit(ifilpl?►i:ablt) $:GCrtltir9tir)ti:
11/5/2022
5322 US-158 Advance, NC 27006
Plt�,sica1 Ad&c$s,i1y.-a►id Zip
Davie /la•,Tignlne this Yawl, 7 Iiere4y r&6#,that the, -efi f 1#,ac tworei oharrrhmed in
t:tlitlii` Arrrrt ld:aiificiirkrn'No.(PtN) rri;C'i,►tlirtur'1rttlr l<.d_l(=ii;�l'!C;, d(tt)�rTt_',0200�Iflell Cz,rnOWC.1ion Staofkrrtls
and Brat o COPT orf!lfrs rcrdn d kf,s.tbe"M/mn ytted to ilre well ow-nor.
51h.Iaitfoide and long lW&in dcgrres/m ntttes/scitoi's orilecito itcgrres:
trt�ici filA,ork La tpng s ,trL ntj 9.Site dierant nr additional will(lawns:
1 ou relay'use ti►t back of tilts pad e`to prof ide addrtiianal ell site detaits or wall
36.00464141 -80.93853939 �il nbandrrittncnt ii tails. You ivay also attach additionil pages if netedsatl
t-ON TRiRMON OkTAILS 01: BKt[Vt ABAsru()Ni D SU r�;i1TT�r=,��sTRz1S TtA vs
:trt�f/r mail cr,r��•iru�Frorr rr•rr,rlls{ilut�kdrk.'.Fiit•frciillip7r it�triiiri ru ridrn•m'itrri.xuyatifi..'
%ilhtO.V14 wtrh ike�rrnrrer, r n�erK,at mrchr r ,r.,tdn mot ywhfth olw j)i 10a: Fist All-Wells: S A,mit tips foini�seithin 10 JkVs of coffloldion of well
61j.Well f6tieMW-5 abandonment to the r6lipitiin4:
btt'sinn af'l�'aferRcsi?terr��1n1'i,tYttatiiin PrStc�cini;+iTnit
6t►:Tott<t n'eli depth: 36 (ft) lG 17 Mail Scnicc,(scoter,Raiciitt.NC'27690-►611
.10b.:Eki Irtliklion W Ist"1n addition to Se'M1ttg'dwfatfrt to the Adilitt to Iba
6c.Borehole diarncter:'1 {'in) abmt.also sttbinit one top-.-of this forrn.aithifi•G days of ortrpirtioii of trill
abandonment to the tbllovdn.
Ditislon of Water Rcsoore
21 2 is Gttiler91,00nd Injection ContmPl>ragtArn,
fill:Water Ic�c)'hettiit':><twund airfare; Cft) 16k 1liail Servticti Centcr,Ratcith,N 27699-1 Wb
I
10c,Ei'r.Hi!ig 11221y,is Inicetii►n Wells: In addition to Sending the form to
6c:Outercaging ichgtb(if latnw•n): (ft) the address(es) abore. also submit one copy of this form within 30,dat•s of
comptction ot`;well abandomnertit to the odunly health dcp:trinwit of the County
icltctc abandoned,
of lniit:reasin�tnhint;lrnynh(tf t�rp'�tn): (rlt.!
69.Sctik*n length(if Wo t`n)t
Fenn GAF`tfi North CaroUrn Depanin rid of Err.imnn►crtt and N:iiurat Rewiuces-Division of V.atcrttes iuces Revised Anosi 20 t i;
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