Davie_Well Abandonment_20221118 (2)

W LL ABANDONMENT RECORD rot inkm:il v-q—.OM `I.'
This form cdn be used,foe single,or multiple wells
3
1.Well Cont'rachrr infiirntattgnf WELL ABAND( N`MF?NT OFTA tS
Robert Miller _ 71L Number df hetf,being ahandooeed: l__..
Well Goixnetorl!tsme(or well ovtiaY Pi:n6lctl nbiwonin a.tl on higw't prwnc %) }'ru ar�dnrte rnpcc�iiur +� air+-iPrtrer aw�Ts- ui dfs 'ONLY +atth Me <ruiie
rvxt�rr+rrdrtx,rnrr irnnrnr rrt,;yrrr�r�t�r»,h lr7f Tarr jr,rt�,
2675 A
7fr.Atipniaimatc�vrlaim of srat�a=n'maittia�in���cli(s)i. (�01.)
NC 1VOlI Camastgr frrl ificalia�3 Nri q�icr
SAEDACCO Inc FOR WATFR;$UPPia'"'f. $ONTs
Co"r''itt4 NafML 7c.11rtrc tot ilisinfCctant u3ed.,calcium hypchlorite
3 �i'dt consttvctian P�tii'mit#:
13c!«ft.e rdt rh?2 irrll FtrnrYl li.r.Cvantl. & i.l'u farnci lihravina.;�tt•:t i(t"rrf, ry 7d.Amount of 441lifedsot u .10z
i Wei u.r(cltccicwill
water Supply Well; 7c.Scaling materials nsi1 tchccic`ali that aiintij
L7Apicid, iml Dhiunicip,•tl%Public 6i Neal CcinOW"it !)$Bcttton tc'Chips ort'cllets
Ctfict>thcmi6it:(t4caiin,)(*bol n 'Strppt-,•) DResidetttial l4'atci-Sutstih•(<ingfc) D Saud GCnrtni tti>nt D i7n'C laj'
t]itdllStrialfCOmmctri tl DkeSicfctitial Wnitf:Supple(shared) D.Concrete Gmut D i)rio CSllfio
Ottti atiotr El Spta~.ialti•Gtow D Gnml
Non-fyater•supply Well: 0;'®ettonitc Slorl O°Otbef(eaplain under 79)'
�tv4oitiforirrg DReeostn
lnjcctivn well•; 7f.Forcach disterial,selectted alrt ve jwrovidc amnitht of_miiterialsnsvd:
Drlquiferiicclitrgr OGrourul>tatetRrntcdiatiott Neat Cem.:941b ,Wtr:6ga1. Sand Cem.:ib ,Wtr:gal.
DAt)uifet Storage alw Ftecrmety OSalinit Hrrnic
DAilttife-tTes4 Bentonite.:31b ,Wtr.-gal,.
DFxpbintental Tothoolo DSitbsitktr:e Corttt9l 7g."Pr`iride a brief deseription of the absiridaftluent POwedurrt
bOwtherroal{Goosed l,,M tlTricef
Trimi from bottom to top
t�Geothcrntttt.(lie r"tin tiCoolin Return) CJOttnerievis"►n under 7
.i."te0%91(s)Abandoned. 11-2-2022 NOV 1 Q ZOZZ
Sg.Well location:
1n;�c-y£3','.�1 . :=�•:ei:o7 11r^r6i
Walgreena
rkilit}'lClscn:rN rriie 1Taviliig ma(iFitppli 7hlc) S.Gcrtlfiration;
5322 US-158 Advance, NC 27006 �j+�• 11/5/2022
PM,sical Addrrzs,.Ch .-arid Zip Date
Davie py++?gnftru this f}rm,I hereby cer#4'that ilre wells)wK(IVC a dhevidoned it?
Co+unv Nrwi ldt+tli iciti in No"(PIN) rrGtt hAvirr�v 411 1 ki CA(I�'t.� (i100 or? ,!)?C,NY 1 11('i iSlraltltCrr,,Gtm<kirtls
and 11u+r a cppy Of dtis rmwrt)Isla/been prmie d 16 the trv11 ow-ner.
5h..laitilude and longltpdc in ticgrrt slininttteslscr+ads or it xinrAl degrees:
(irn�ftt>Lta.ar>z t rt:t ug i,,rtrr; rt} - 9.Site diagraw or additlonal,%�ll details:
You inlay ilse the back of this pale to provide additional ithll site details or%M1
36.00471063 )\ 80.43864136 ;4 Abandonment details. You may also attach additiotrApages ifiecemly_
C`6NC1 Rtlt— O"DF 1 A1LS hot 14`1 LLf51 gh 1Nt.ABAN'bt)t1ti Q SUBb117TAf fNSTRIic.Tici
�1lt�r3i a>"t1 cr,ratilruetinn ri�n•rrtli'sr i1 acnitc�,tc. rtu•multipir rrtje�iririN rep Mn�rYrrrr.ixfij+Pr
t+eil.t).Nf.Y'x3rtritre��rmre�icrrxeiux';a►wrr�krrrri�rrr,iurrcog�rhneirerir �+r�t�t. 10a.Far All !►Vcilci Submit ifiis toms-%1�ithin 10 dayi of completion of well
ON.Welt to MW-3
nb;indnnntrnt tithe folltiititng�
1)h�isirtu of N'atcr'It��tttrrs-,yatitrrnatitln PnrcessVnt;Unit,
fib,'Total well UetNh:.35 (ft.) 16,11 Miki1 Ser%ice�:eenter;Raleigh.N 27ti9i1-16'1 i
yY . ec640 W seiiding'tlit folul to theadd ess fn:lba
10b.F l I N'cdlc bi ad'dition to.
fie. turcltnle tlVamc#ew 2 (in:) abo� .also'Subinil oue Coln of Itlris forrst_-,tidtia 10 days of LVtnph4ion of itC11
abandontnent to the.fallowiltg:
I)i+ision of W,itcr t trurrrs V den round tnjectlon Ci►atrof Fixigralu,
"fill.Water ki-el beltrn•Ownd mrface 26 oft•) 1636 Mail ScAice`C"entcr,Ralcigh.Nor 2769')-I 636
lOr. Lr '�tcr Jtnnh;tC ioit tlnn lt'etts: .in addition to sending lbe fom:to
6c.--Outer casing lenob(if tc iwwn� ): (ft l the addresses) above. also subniit one cot>*' of this f0rol'%fiitbin 0'dams of
completion of%iell abandoninenl to the Couniy tkallh depaitntcttt of the cmittty
dt tnaercast"futnbine length(if known):
Mime abandoned. '
fig.Screed length(if lionlifi): __.__.___(ft.)
Farm OV-1h Ncnh arotim Dcpantrrri oMwironn-writ and Natural Resoirces-NsIsian:of W:iier Resources ttc,scd Ailgasi3+?I!'
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