Union_Well Abandonment_ (4)

WELL ABANDONMENT RECORD Fotl tenW Us ONLY
This form can be used for single of multiple"ells
1.Well('ontrucmr Inforinanos: WELL ABANDONMENT DICTAILN
John Eisenman 7s.Number of wells bcwR abandoned: 1
Well C1]lemCMY N]nIL`IJr N.II nN11LY prIY11mII1 JI1l1YLlmn'(.Neil On Ill:1w,pl party) Far nmh#* olonttmt tr nuv-rum n"M wdb ONLY rlfh Ike tare
tvwbrctka.nhaximmu ..on rem wMa raw film,
4439 7b.Approximate iolenar of water rtmandal In%dl(,P tgal.)
m NC WeII Camrag Cc"Ifc me. rM%,
FOR WATER SUPPIA WF.I.t cON'IA:
SAEDACCO Inc
Compam Name 7n'fxpe of distufartam uwd:na
1.WeN Construction Ptrm..k,
fiwJf.yplkoDl,NrB rr.mar n.e.CuNv..]lade.l:raaaw.lnfwdx ek.l lJRtmrr 'it. %motouW disinfectant uscd:na
3.Wdl aw(Clica weld nt):
Water Supply Will: 7e.Sealing materials uwd(cheek all that apply):
OAgmultural OMmdcnpalrPuhle N Next Cement Gnarl fl Denonite Chops or Pellets
O(icotherlml Mcatrnig feeling Supph I OResodcnmal Watt Supply atingle) O Send Cerveni Grout ❑ Dn Clay
❑lndusinalA omnmmial ORc dcuul Water Supph ishamil) O Concrete Grovt ❑ Drill Cuthnp
[11ingailuji ❑ Spaialn Grunt ❑ Crawl
Now-lA ater Suppb'Well: OBertomfc Slum' I l Other lespiaua mden 'I,,
XNlumtonnc ORmmvn
Injection Well: IF,For each material selected alwsc.pnn tdc mrNmnt of materials uw•d:
❑Agmfcr Rechtrge OGrnusd"aler Renrdulron Neat Cem. :991b ,Wtr:7gal. Sand Cem. :lb ,Wtr:gal.
❑Aquifer Slomec and Recm m ❑Saluwh Danner
OAgafa 7'esr ❑Stour wa DrAlmgc --
OExpatutcu d imhmbkn ❑Subuticce Control 'fld,Prexitle a brief drw•riftno n"t the abandonment pnwrdure:
O(Cieolhemrd lClowd Loop) OTfacer
OGeoth rural 11-lannipplCooling Rehm) CjOftr("plain under7 ) Overdrilled and removed well, tremie portland from bottom of
borehole to surface.
l Da4 wvld(s)Ahmed*" 10-31-22
Sa.WEN Int"doe: NOV
—�
Kills Cleaners
FacilihdOrar Nmrc Facab•IDr of applicabkl ld.CeHifkatloa: ID�O;Yi;iC� '� -
j Uri.
1305 Skyway Dr, Hour", NC 28110 .P„9.30(3 21/13/2022
PIN seal AdAca.Cat.and Zip 5 .- ...LL.-. _. -
��� � a 'wri i!»{�-'6'La-�vrNt Odle
Onion By rgpung dw Na Air wdffs) war Iwerel mhaidaned of
C'oraas Peed Identification No.(PINT «'<rwrhaae onto IJ.f.SC:#C O:C'.II10Dn X'.QW Kill(iwtim f.,m V,m,AInJ.
and thw a cop, of this record hav hewn prcn-uAd ro the trelf oN m.r
Sb.Iadmde and lontitadr in drgrrevininou truwtrrnds nr decimal degrees:
Gf oell fr-Id vie I:ro kmg n.nnmtn 1 9.Slte diagrann or additional well dleudv
Sou non tnc the bad of this page to prat de addnnoml cell sac loads or"ell
N W' :ibandomnew dewd, 5'uu nnas alw attach additwmd pages if nrmasan
CONSTRUCTION DETAIL4 OF WELIfS)BEING ABANDONED SUBNIIITAI.INSTRUCTIONS
.Plot*.111.nrzrwcnnw months n"wItk • F;v mdnplr nwuo-..rr rot-.veer a{ph
.dh ON'Lr.,m rle um.en w.,.e..rr N,.m IOa. For .Ul WcW: Sabm Ibis form aathm ;o dap of compldwu of %%ell
6a.W ell I1)4;NW-3 ahandonntem to the follonme
Disistow of W'aler Reamrcm Information Pnansing Unit.
,.h. Lnal Nell dcplle 36 Ifl.l 161?Mail Senice(tinter,Raleigh.M 27699-1617
10b. Fur himisju Wdls: In eddiwo to xiduog Ile font to the;ddir»m I'lr
6s.&nth le dlamelce 2 abu%e. Aw admul one copy of din font milun III days of completion of I%II
Iln.l abatdnnmem lu de Inllounnn¢
lftl Dr%Won of Water Resources,Underground Inpvtion Cowlnrl Pnngrani.
6d.Water knot brunt gmmnd wrfur: 19
161e Mail tiro itt["toter,Hakirh.N('27e9't-IdwN4
ma der. For Water Swonh & Inirelhro Wells; In addmoo In a-(Omg taw fomt to
mr.Office casing length rif Into.n I: /del the add !esi abort. also suborn ota cops of ohs funs t,thut Ida dass of
compktaon of sell abardanmmnn at,the :orals health dep:mnouv of the coma,
"
Lf.Inner easinghnhing km t9b(if kno"n): no heft.0mdo d Ihl
6%.Scorn length(if Mon n a:na IR.1
NuahCarolam DApnncoofEmtmmlemal Nmuml Rcwuacs Dnaronof N'awf R.ouacs Re.ed Aovarn ball