Davie_Well Abandonment_20221118 (3)

WELL AB&NDON MENT RECORD rnr lydicmii(Toy(71+p,1'
T11is t�i;tit can Ue usedJbrsiitg[e orrnultiple'�°oils
1.Well Ccrnti:Icio'r 1(rfijrmatitini 1VFLL A8ANnOl1MENTf J)FTA1l 4
i
Robert miller la.Number of twelk hei►g abandd'ned: 1
�1'rtl Cow-Ihor Name(or well ortxs p r cindJy:nLi�»9anin acJ an h#?thct ptopcn,i tr+r nrrr'tnplr 'trjtc troir %u tr+H;i�rt+ su h° w Tls. ONLY ratrh .tlr -same
_ rusr>crrtrc'pt+a ntmr+Q�atetA,gtu+z or;�hr rrf.rt�,�,ritr
2675-A
NC1t�cllComnperfrnif atitisNrrn>b 7b.Alipimmate,%Wu eofvah',r*nwininglneicll(9)i
SAEDACCO Inc FOR%VATFR,StJPP1,'V8V.U.S ONLY:
Con famyNarrte 7G-f pe of ilia ufectant IfWj calcium hypchlorite
2.tiV�I Cotastriac'iion i�xtitit M; ,
hy.0T lkw6le k PT;ermilr jir.C'wnt Ct"we,'l urtfirwe,11ge-ii-aa,tit'.i!IA-10rr+t
7d.Amount ofdisinfecisnt ured:'loz
3.Wellu•c(checkyv(it 1180
Water Supply Well:., 7c.Scaling matciiahs ascd(check i1l that app(c)
COAQr arttttraF 1_amunicipal#Pubikt, tt Neat Ccmctii,Gnm it 6t 13cnt6mie Chips-or Pclicts
l7Caoatltemk7l(HesthggWuolin-',SiTppty) 13RCSidsrtial l'ater$npnt%.(sin�tc)' D Sand Cenkat Grout O 1 i Cf y
Hindnstriait oinmcrr al t3ltCsidcmial iVa►er$trpph fsharrd) ❑ Concrete Grant D grill Cltlting
i7lrri=' ion p Specialty Grunt; o Gravel
Non-lyater;Suppkv Wcll: 0 BentonitcSium.r 0 Othei'(e\-plsinunder 7 j)
99Monflor a l7Retortw
>injcctign Wett:, 71.For,each.ntatet ial,s0toed Obove..provide anfoimt of.mytteliols V'sed:'
OAgtriTrr Jtcrti rl t (JGtound Qer lttirtEdiHtion Neat Cem. :941b ,Wtr:6gal. Sand Cem :lb ,Wtr:gal.
IIAqu fey Storage And kecovv�, t3Sahnii Hanicr
13AquiferTest OStonrntaterY7rairogc Bentonite.:31b ,Wtr:gal:.
� > :�inrentaf'Tachriolo)t3 0 iiWdeice Cojitrol 7Z Pritvidc s brief iickription tit the Aardnnment procedure:
tC.6osctl hoop) lTracrat.
CiGeothentktl(He itin `+voolin Jtetam) [J()tttcrle\ lain o6der'7 ) Trimi from bottom to top
4.Qaie0vil(s).Aan.doncd: 11-2-2022 NOV 1 8 2022
5a.Well tucati;in: Ur.lb
Walgreena
racilWf)wnm:r`N;tme 1 atgits'it)rt(iF'iipbti able) S•'Gcriliicuftpn:
5322 US-158 Advance, NC 27006 11/5/2022
Plrt sICSliddress..f ttc: ttd Zip �iytsa.<: a .. `,, 'i '*'F!.s c►i ll;tte
Davie At!signige tlir'c/+ann,I hereby roniA,ilia!the w°E+1tic)was(tr"r abiwdwred in
Cauriti ]'area1watif ittcohlome,rilhtlit t—lC•fl2C",A(O,orIICA�-Vi)Well CoitsliVCu0riSWjri&1rth(-
ctnd ITrtrt a:cnT+tcnjthis rrc rive!lots bcirtt{rrrn ider!tci!lire ts-e11 aw'urr.
5b.Lvitihrde and longitude in do rrrslininittcclsccrjnAs nr d cimal degrres:
(it nc li Ella,atk tirr7a,rg i. �,1T,�tieq) 9.Site diagran)or additional"-LAI detAlls:
You alai,one the back of this Oft to provide additiaitat 0101 site details or tc'ell
36.00469105 -80.93858985 NVba,tdonttiertl details, You ntay aiso.astflchat&iiitotkil ptrgcs ifitc.cssan
t0Nq ''AIJC-r10?V'QFTML$OF WELUil jF1E1KL.AdAX60NtD SLIMMAL RMLI T[QYS
.iwsrlr W1 rv)twrvdkw rtrcyodl W rf aiviitral+k: .Frai•rrultljt r it 4tiirlrr it rxhti•i,Ytdri WplPi
Brett, t>1!,) »ir r i1,F.wm,rurca wer rrn' u+rtAa+fm snt,i,ln z d+a mhftii more t K ltla. Fnt i111 V1'cllz: Submii tli%t'fotm:iiittiin 30 dots:of completion of'w0l
phandt)nmcaf to the fotlp�tins
6a.Woll tl)#MN-1
VO4inn of Witte t oumes Information Pmees tng'Unit,
61P:Total well de)itli 35 (fl) 1617 Mail Scnicc,e`pter,itakiih,NC 2160-1611
lob.•F+i to 1 c1ton ldli hi AddK66 to schdiog AW forrtl to ttitis address to 163
(in:> abort.also submit ogle top-0f ltis fanu-ivithiii 50 days of.tooWitgioo of hell
o 6c: rchole diameter.2 abatidortmrcnt to the following
fri.VVatar lcticl hetaw' tmd xu`rfacc 25.9 ) Dl+lslon of W,ltcr Rcsonrrts;'1ulrigt uuad Tit -Coon Ciinftul lr)arAnt.
1636 Mail SCrtiCY enter,Wttc►fih.\'f 27G9y=163b
Joe.at ` tee rr)rth,tC Joicction�t'elis: in addition to saiding itte farm to
6e:Outer clang lenttth(if lmon-ri): tA) the address(es).above.also Sal mil oat cope' of.this fort withih 30'da,'s of
completion.of�irli ahanda►tmcn't to rite count ho-itth dclstittntcnt of the county
wh ac abib domed.
4.lnnCrt asing/tnhing"Igh of talorn): .
6g.SttM' lengtb(if kndit't): (h.)
I
pnnn OW-In Nori ti t:aralim bepannr:rd afEm irona)enl arks Nituml.Resources-131cision of Waver<ltmaii es Res lsetl.Attgrtst 2013: