Union_Well Abandonment_ (3)

WELL ABANDONMENT RECORD Fo,lowroll Vie Wh
This farm can be used for single or mdriple hells
I.Well f retractor lnfnrmatioa: W'FLL.ABANDONMENT DETAILS
John Eisenman In.Numberof nelb bring abandoned: 1
Well('nlazava Na.,e,wdlow¢r perorulh Andowag wcO un na;her poinlyl Fry mnlnpk .,ir, 0%11 .ub Ih .mn,
rm,rm.n,xr„Famhume•nr nx, m orfwrn xo-,bon
4439
W WCll Convertor Ccritficatwn NxnM -Ir. Appn,sinun'so6ntw utwafer remaialaR i•weWalq lRaLl
SAEDACCO Inc FOR WATER SUPPLY WELISONLY:
Corrpms Naar lc.Type of dlsfufectaat used:na
2.Wdl Cooatmtfon 111"
., ,tt";vde en!,xdl lrrnrt.lice Cnvar9.$wk.V—twtce,fryeer A.e;, Ilknork
id, \m(mnt of dial nficum uxd:na
J.Well use Iched:well axle
Water Supply Well; 7a Staling materials used(rlhv'k all that apply):
DAercnhurd ❑Mrmtcrryd.Polk itNear Cement Gnkn ❑ Hematitic Chips or Pellets
OGennccmed IUc aunz(ooltng Slrpplll OResrdcntal Water Supph lunglcl D Sad Cetrcru Groot ❑ Dr,('lad
Oldnsmal.(ommened ❑Rtsdcntal Water Supph rshared) Ll Concmuc Grout ❑ Drill Cutump
❑Im•Ilion ❑ Spmalh Grout ❑ Crawl
Naa-W ater Grpph %%ell: 0Bemomre Slum II C)rher lerphnn utrdt'yi
®Moatonue DRasmen
Injection Well: 7L For each material sclettcd abosc.pros We ankmnt of materials uwd:
OAgmfrr Recharge DGmuduatcr Rertwdrafton Neat Cem. :941b ,Wtr:7gal. Sand Cem. :lb ,Wtr:gal.
DAgra Err Stange and Recosm CSalnun Uamer
❑Agmfa TeN OStomnsulcr Drains env --
DEvpaimrnml Techinal OSubudetcC Camrul Pr„1 ide a brief desa ripunr of the shandrmmenl pnwfdnrc:
CGeotbemwl(Closed Loop) CTfacer
CCtmhemW(Hmri 'Coop Remain) CQheH in under / well abandoned in place, tremie portland from bottom of well
to surface. rF�+
S.Date ws•Il(al Abandoned: 10-31-22
5a.Well kpanon: NOV
8
Mills Cleaners Ir1lCi'1:9;•?ef 7�— --
d.Cef181ra11N: �,u' 'Z JC-•--,�
fcdm()„rrr V:un Fxiln TUN(if aoPlit6tC1 ra,
130S Skyway Dr, None", NC 28110 i -- 11/13/2022
Pb,seal AdrYcs.Co.and Zip Dare
Onion 8t aRmMf alfur ._.•tiff'dia the walla) war twere, rAwal,rfled or
Come, ISnd lJ,adiAnn No.IPINI r vocirt ua'e with lad AXW 01C'.0I00 ur:C 02W Well f iurrlrv(n.rn.Vemrlrmfx
mil llr.x n c[rfA of this rerwJ has Gem print<h�!br!h.urlf owner
Sh.I.Avulturle and bnpdtde in(kpenlmimrfnluvslnAs nr decimal degri ta:
ul a 01 hid nix Labrrg a saf kern l 9.Site diagram or additional well delailr:
YOU Illm the 11W back of this pope to prm tde:Kkbhorui udi site M311S or fell
N W' abandonment details. Yw mad dsO:atach WMlocrul paces rf oo'c san
It DETAILS OF W'rl 1/S1 BEING ABANDONFn SUBMFCFAL INSTRUCTIONS
uoxlr well mngruarnxr rcc.vAn,rl o- ,,
.d1.a06Y.ab kx s„nw r,m.nnn Itta. For .All W'SA: Stbnut (has fmn wnWn all dass of :ornpition of well
fic%%ell I1fA:MW-2 ahadonmcm to the follnwan:;
Dhisiun of W afee Rmnion ,Information Prosnting l'.air.
6h.'IWaI well th'ptlr 48 in 1611 Hail Se-nice('enter,Raleigh.N( 27699-1617
Hall. Fur Inflection Wdls: In addition to sending the loon to the address m loa
be.&m•Ikde diamrtrr 2 abuse. also Amur one cop) of Iles (unit olllnrt to doss of ;onrplrnon of dell
abutdonnpru to top lollulsutg
rsd.Waer kol bdnw gnrunA wdarr: 14 fRj Dhrslun of\Pater Rnourcn,C'ndergmmnd Injection Control I'Mra>>
1636 Mail Senicr Center.Raleigh.NC 276994636
Inc. For Water Small, S Inrtkm ie W'eBs: In.ddnrol to with the foal to
6c.(lmrrcasingleci lit lmonnl: na IN.1 the addresslest allow. also submit oiw etV,% of this form %lollop) 71) darls of
completion of sell abarakument to the court hcahh department of the from
where abandoned
r•(. Inner cAsing'tw6ing hnah tit Mawni: na
6g.Salim length(if Lnuwnona (D.1
Fom(iW-Br NonhC'arohm lkponlrcnv of En.rurmpra aN vyorai kcxuwcs Dn nun of WnNtkwum> Rs'.osd Auguw belt