Union_Well Abandonment_20221128

WELL ABANDONMENT RECORD C Forlrmul G¢ONLW
This foml on be used for single or mollipk Hells � \
L Nell Contractor Infnrmatme �\ WFLL.ABANDONMENT DETAII-5
John Eisennan \ 7a,Number of wells being abandoned: 1
N'<II('omrxtm gene L:,,,;o.,:,n,I�a`.nrlh alnNenun ..11.nl An la,pngm•n� o mulnrl. rnlr,n,w ,c tom-+:nn ral9n+' aril, 011f wnh the %aK
i .rFnnl Ili MI,�7•arxl,/HMlI1l.I,�e(YN a+Wl/f iMlr hlyl
4439
NCWetl Caewar,Ceoolicoma N. ix 7b.Appmeimste%olarnr of water remaining in well(%tP IRaL)
FOR N'ATER SUPPI.I 11 Fi.l S ONL I':
SAEDACCO Inc
Co1Tua'Name 7e 1'%pr of d4unfertinl used:na
2.Wdl CttW ncthrn PertmN d:, ,
fur di,ptAr.xM1f, �. ., „ ,eM.11we.I�nmar fyeatmn rh.�7kerxx - --
Id.Amirrnnl of Jiunfcybnt uxd:as
J.Well use Icheck w ell u%el:
Weer Suppl% Well: 7e.Sealing nutmals umtl icheek all that appl%):
OAgrrcnhurd ❑hlrmtclR1LPubhc ® Nor Ccmem Gmlt fI Heraomte Chas or Pellets
OGealbemm(Hearin,('aolmg Supph i ❑Residmial Water Supph'Ismgle) 0 Sand(enem Gmul ❑ Din (Ln
❑Iuduslndj ommcrcal ❑Resukmal\l':ncr Supph tslaucd) 0 Cotw-tete Clear ❑ Drift('mnngs
❑Ito itun ❑ Spessuhs Grout ❑ Gm%el
Noma-Water Sal Well: 0Bermomte Slum 1101ber(e%phun trder 'gl
®Momtorong ORecu%m
Injection Well; 7E IMoth miga0erial reiected abuse.pn%ide Amount of material%u%A:
❑Aquifer Recharge OGrmidoalm Rewtharmr Neat Cam.:9411, ,Wtr:7gaI. Sand Ce-ra. :lb ,Wtr;gal.
❑Agmfn Srarogc aid Rr.rn m ❑Salwa Hamct
OAgmfn 1'esi ❑Slomasalre Drainage
OE%epmrrcmal 1'nlmoon ❑Slbvdctre Control 7g.I mide a brief description of the aband,mment pmcnlurr:
CGeollemml(Closed foopl I.ITracer
13Cwhemtal(liobn •'Cools Raman) Writer(explain under 711 t well abandoned in place, tremie portland from bottom of well
to surface.
4.Dale welldsl abandoned: 10-31-22 s. R, P�_i V
Sa.Kell locution: NOV 2 8 ZOZZ
Kills Cleaners
Facial ln,�.,Vance F.x,ln, IDr of applyaNkl R.Certifications: IraEci T:a:i:"1 �ai�;�i'di;^.� L,.
3305 Skyway Dr, Nonroe, NC 20110 - - - 31/13/2022
Ph,malAddess.Ca..adLap sfL'.sa,.. .':;a3 . ,>c. L-!.-o•'L a� .%scr ..- Dale -
C ia'deir r+e✓r
Onion fit "Knn¢I star a/y fMr the wef s, am mere., dtms/arnd in
Cnm% i'.n:d kknal,,imn No.(PINI 1.1,,nitm'ewa7r 15A.W,ICOX'.O100or:(- 0.1W 1t i•11f%mrrnf(hon.Vao(4ad%
and that a e-ape of it record her hem pno-rdal to the well nw ner.
5b.Iaritudc and ongimde in degrervminutevuvnnd%or dmireal degraa:
Urwxu r.m.orc he ens n.nn,ccu l 9.Site diagram or Additional well(hta0s:
You nun me Ilse back of this page to pmsitie addihaul cell sire details or well
N W' abanlottnern deans. )allow also.dtai:b additional pages if mi;rSian
CONSTRUCTION Dr.rADL50F N'EI 14S1 BFING ABAN DON ED SGBMfTTAI.INSTRUMONS
Itrarh awl!mnruvor. ..,,. apph
102. For All Wells: Sabmil this fame ntlhm ;a cans of completion of well
aa.Nell IDC:HW-1 abandonmatt In the following
Dlridoa of%mr Res,mrcm.information Processing I an,
fit). Filial well ioplh: 33 Ifl.l 1617 Mail Sen ice Ceomr,Raleigh.N('2'bw)-1417
lob. For Infection Well a: In aSluun to xtdurg the Iona to die address at lua
abu%e also stb no one copra of Ian form, warm a)dins at completion of aril
M1r.&,rdaue dlameh r:2 Iln.l abuldaunutn lu the Inllus Ing
DtNuon of Water Roemmm,Cndnt;nund In jraton Conunl Pnrgrar,
.
bd.Water level below gnuml wtiare: 14 (ftl
1636 beach Sen itt Ccmrr.Halcigb,NC 27679-1636
IM.Outer iyung length are hnonnr ^a IRI for. For Water Seoul, J, Inkrlo W n ell,: In a moo to setae the form to
Ur :ddress(esi abme. alw subnut ale cup% of this bait auhol 11) �a of
completion at "ell ibadommin to the coon% heahh depunnera of the count)
u here.abandorcd
hl.ouercasingaubmg length(it krwonl: ^a ft.)
fag.Screen length(if know o a:na Ift.)
F"o"law-:.. Noah Carolina lteymm:n of Emmiomnem ad Nasal Resaacts Chs aeon of K'aei N.u,.ms Resod Aagra Mal l