Mecklenburg_Well Abandonment_ (20)

WELL ABANDONMENT RECORD Farlmnml Us ONI)
This form can he used for single or mdliple wells
1.Will(imtrormr Informatos: WELL ABANDONMENT DF.TAII Y
Brian Ewing 7a.Namber of well.being abandoned: 1
Well Cutmanor Nam for udlouun prsurWll uhawlomag meR on haari piaperly r Far moo of nUnhurr a na+u,er ruPpL „Ile ONLY old, Ito sane
r+xi+nn,n,x,ah,nnhu,mrnr wx„w ovbnn,x,r frmni
4240-B
NC Well Coogctor CenifieA.NanFn 7b.Appmtimatc N ulnmr of w JIM rrrooitining in w ell(sl:
FOR W AM.R StIPP1.1 W FI.I--�ON1.1':
SABDACCO Inc
Cow",Name 7e T)pr of dhdnfiertarn used:
2.Wdl Ca UrMtion Perak 0:70003075, ,
La.Af,yrp!„oAr. .,.n ir•mi1.•,.r.I,amo,11we,r nrta,wr.byvenule ea-.I o bso.n
7d.Am(met of disinfttlanl used;
3.Will use i(heck well aseY.
Water Sopph Well: 7t:,Sealing mate•nads mnl check all that apphl:
❑Agn;uhnml ONhmcip:il'Publoc MNeal Ccmcm Gnat ❑ Bcnonitc Chops or Pcikls
OCiotherind(Hwntie(oolong SupphI ❑Resldcraml Water Supph (so okc) O Sand(enoen fount ❑ DIN CIA
❑Itehstnul.(Commerctal OResdenual Water Stryph(shared) O(ae-Km l Urom ❑ Dull Cuttings
❑Im-Iwo ❑ SpecaR) Grunt Cl Grand
Neu-Water Sgpph Well: OBcoaonne Slum I l fkbcr lcythm,mdc, 'ei
®Aiumlor o, ORermen_'
Injection Well: 7f.For each material reflected ablose,pnufdr anm+lo r of mourns owd:
❑AQmler Rcclarge OCitoutdwaler Reinvit Lion Bost Cem.:471b ,Wtr:3g&l. Sand Cem.:lb ,Wtr;gal.
❑Agmlcr Storage and Roc-en m ❑Sallmn Bamer
❑Agmfa Icsl ❑Slomm%wa Dreuagc
13FWc omenml lachi olog) ❑Sdrsidctcc Ionoul 7g,Preside a brief description of the abandnmoko rooeraE
OGeolhcnoal tCbsed roopi I_ITracer
Ol'Ieofsmial tHerrung,'Cooling Remmi UOrhcv("plain madcr'gI tremi from the bottom to surface
).Date wellls)abandoned: 11-1-22
Sa.W cb kaalion:
Norfolk Southern Interisocial Yard FIT,
N.f\•ni0talinu: �i Q1�x
Facdin,flwmr Nnl,. Fac,bn.ma,rt:�pple„nki
333 Parkwood Ave, Charlotte, NC 28206 Brian_ Ewing 11/11/2022
Plascal Addi s.Cm.and 21P srw+sa.r.1(inam w'ca, .:II Owner DW
Mecklenburg 08301126 Ih signing dov Jiam. I h.„n, a that the n'elffal now fivene, ,ahwuh,.md m
Coma, 1`,,W kholIvX.„No IN%, agxvdsecrwofl,Pi.4X '.aCO2C,0100 arj(- OYlfl Itell(inrnwnun.VendaM
and ihar a crIn of rh,.r record hus hen,rnnatw In fire uell tm ner.
5b.lamuude and longitude in de•gevrvininusruwvvmdr or decimal degrees:
(if.dl field o,.I:n bqe n.nn,xu'f 9.Site diagram or additional well detsik:
You nun use fire bad of fills page to pro(ode xWtitwed well sae details or well
N W aban o uiettn details Yew neiN also atach adduwml pass d,oecessen
CONSTBDCYION DF.'rAll.S OF N%FI.I I}I III IN(. %B(\DOVED SUBMITTAL INSTRUCTIONS
.uhah.r1/u,mtrv.r,... mr mtq•A
.ill,ONIA ugh xx Via. For .All %06: Sultnut Ihes toms wohm - , dus u1 canytfdoou of uxll
Ise.Wr1111)v:17(47-7
:ib.ndonmcm m the mOmN,ne
INrhinn of W'ster Res(mrrm Information Prue"v rg Unit.
eb. Intal neil(lepih: 15 I(L) Ion'\tail Senior(enter.Raleigh.N( 2769-1617
Inb. Fur lnleeNon Willa: fit mUtiwn w widusg the tone to the address in War
oc. RI'lmly dintwler 1 tom.) aboee Au submit one aM.% of Ibos font wtihin III"s M completion of well
abaiaknmiem lu the Inlluw IM!
Dmsiun of W ater RIcrres,t ndetymmnd Injection Conimh P"Mram.
oil W atcr lerd bA.. urface: (ft.) I636 Nlail Seniee Center,Raleigh.N('27a99-Ib.M
(w.fluter casing length,d Momm: Ift.) Inc. For Water Samoh & Injection Wells: III addition to sending the four to
the address,esl abene. also xlbnn( one corn of this fomt milon In fins of
:ompletwn of NNell aba dmmtcm io the cotmis lic.ahh deryDonwis of the count
rN Irrc aMldmaJ
fief.Innrrenino,,robing ktit9h 61'known): 5 then
6a.Scorn length III Maw n c 10 (111.)
tone Ow-a� Nonh CayhrulXfunncnol E,,,aJilli.iNatd Nal iRe'N cs DINnWaof Wascr Rsouires Maed AaprA 94o