Union_Well Abandonment_ (6)

WELL ABANDONMENT RECORD u rrCl}
t This fdml can be used for single of,nuluple nulls
1.Well of ontrarmr Information: \1 F.L1. ABAVDON51FS'I'DFTAll S
Robert )tiller 7a.Number of"As brag abandoned: 1
Well Coraricrw Nana ruf wdf o%W p"lolh Wprdr„Ang w•tl on his bet poise"'. i,r ,..m,lr .flue n.n •r +ell! QVL) -ilk the were
rattan.nhawdwan+tl ,au uvr wewn fmr h,en
2675-A
76.Approximate swlemr at water rr.arrg Y etlNak (AaLI
NC Well fur+ncun fcnrfv:alx,rt Nvv6e,
SAEDACC0 Inc FOR WATER SOIOPIA'WELLS ONLY:
It.T)pe of dminfactAnt usrd:
2.Ndl(LnN rndkm Varmd s;, _
La,dl,a.q.i:..ni. u<if;zn,ea-v twN,t 9Hat 4,nwer lq,ra b,ve O..,,(AH.nn�
Td.Am,mm of Ai.r nln um u.ed',
d.Will mar(Ch"k"Al eel:
M ater Suppy WAI: 7p Scaling material,used(chcak all that apph):
OAamulnual ❑hlnnrap:d Pnhl,c D Ncn Ccmcm Gunn d Rentonnc Chips or Pcllcls
06t:othcmnl(ficaunc('aohfr_A,pph I ❑ko ld:mlal%%arcr Supph uur_IC) O Saud(emew(imut O Lin('kn
Olodimmil(onrmer.al aR:id:raral%%.ocr Supph nlnred) O l'fnkmlr Great ❑ Unll Cullmp
Olrn^non ❑ Speaalh (uoul ❑ Grasul
Nan-\\Ater Supply Nell: O fie coon;Slum I I (titer(csplam ulduf"el
■Ntuuflonne Okmosan
jection Well: 71I.For cxlr msterial selected atone,prwside amount of matrriah mnl:
❑Ayuder Reckuge OGro n dealer RenNdrmlon
O.Aquil"Storageatd Rc mm ❑Saloon Wafer
❑Arludn Teat ❑Slonnwaict Draunge Bentonit.s.:50lb ,Utr:gal.
❑F,Lrnmrinal labrfube> OSubar,knr('onfol 71c.Provide a brkf 4neriptinn d the sbaadnnmrnt pnrcadrre:
OGeotbcmml(Closed I.onpl I'ITraur
❑CXdMuul tlfaAnn•CoolingRetinal 1]Othi-mes nunAer7 1 Pulled well and backfllled boring w/ hydrated bentonite
chips
A. Date weRfs r abmulurMfk 11/1/22 -.1._ s`: �7 i_,
eA.\\ell kavtiun: NNV 9 Q �D99
Monroe Meadows
Fxihry{h„u�.n,r Facdn, IDe of appl>:ahkl A•Ct� ID(VP,T.BJ�^,rl iaf::93(Xf j Ufd
Dtr.'0;JJG
701 B. sunset Dr. Monroe, NC 28112 11/14/2022
t� , ..ro•:s .. .' f+�.xr
Ph,seal Addrcas.Cm.:ud AO �::„r Derr
union Ill'vogoll(( the,firm. I heaths rrrnfr that the welly,, wo, New, shnro6wrd or
C.tras i•,r:d Im.oiw:nsm Nu fpI%] framitnar with/d.f A'('.J<'py'.ifloo W.'t. OYa)flMl('wls»orntm.Shfnchnh
and pws a<vIrt ofthiS hYlrtl A,ar 6rfw)rrlefllerl/O are well ornoT..
ib•lAwitudt'and lonritteM•in r1vurvrvminut,ry mond%or decimal delims:
fdwrn r><m ,. Ln s•�:r.,ntl.wn. 9.Site diagram or additional well details:
lbw utn rue the back of this pugs(v pros de addmowil hell site details of nell
N W ;rbaldelmrcm details 1-ou flows als<,Ankh Wdnwnul pages 11 no:essan
CONSTRI("TION DFTAII S OF N'F.LL(SI BEING ABANDONED sl'RMITTAL INSTRUCTIONS
11"'m . o :.n u•H,'•b. ! 1nr!•l• ..",n.or.r. ... ....rr mry•iv
.'0'2\L) ,tuh dr.mrnr om.Vnk,sexy W.n.A•rmmnf m......p,Hw,l.+K bun If)*. For .All \\ale,: Submit this (roue nithin }0 dins of colrrpldn,n of „ell
(a.Well lna;TMN-17 Amidnunrefu to ilk ftMouing
Di%Woe of Water Rrsonrees.Information ProtrnvieA Edt.
eb. Imal well dcplb: 17 Ift.) 1617 Mail Senior Crater.Rakich.NC 276119-1617
lilt). Fur Ialartion WeNs: for addilero to wading the fomr to OK address in 10a
aho,c :dso submit not: cLV% of Ihu form nnhul yr dons of cunipMwn of well
its.ihm'ludc Aiametrr:1 110.1 ah:ndrnurent w(lee tolluuure
Disision of Water Rs rmrn.,1 adcrit"mod Injection Control Program.
6d.M Ater lend hrhuw urwmul wrf.0 r: (1i 162h\lad scn icr I enter,Raleigh.N('27699-16J6
life. For W Ater Surmh d Inin9ion \\ells: In addinon to 041ng the form to
ne t later casing length of Lnow no: Ift.) ilk• addremfe,r Ax.se. Abu subuul one cup) of this fomr althol to "S of
:ontpinmu of ucli ah.vA intivin to the cmmn hcahh depann¢ra of the count)
w In f c nhaldorkd
W. Inner,,sine'tubing k•ni'th ref Woolson): 7 IR.i
ng.S,rarn length fit Wiow n 1:10 A t
Fain AU.'1, Noah Coubm Degoorery of I..,.,lmoncm:ud Natural Reuov:cs Dr,fswnof N:rk,R,.<mfacs Re,and Amptr br I