Iredell_Well Abandonment_20230526

KNELL AB:ANDONN!IENT RECORD For lulotnaaUs�ONU:
'ibis form rut he used for single or mubiple we lls
1.lVctl Contractor lnformrition: WELL A1IANIjONNIENTi)ETA1't-4
Stefan Smith 7a,Number of wells being(alrandl neds 1
lVc1l'C�GLrtBCIOrN�aM(g7.4tiC1I65rI pC(3t19L11J1-1ba8JflllhloUvJI.a71In5111erpragicrlyl I'tw rayfork o!1vellar ar rr,s-lifer srrfy* wells- VNLY wth' Ike ;rvue-
th♦!"fFlfCt7fh7'/71J0!7(IOdI1:JJl:r,atru ccUrsahmlf
I
3576A I
NC Wct7 C[71df1C10r CcitifiwtioirNmi her 7b.Approximate volume of w-uteir rermatinin in
SAEDACCO Inc FOR 11rATER.SUPPLV 1VEL"ONLY:
Cort�any Kam%. 7c.Type of disinfiettant nNe)l:
2 %Veil CUnstruCtgou Pertttit#:r WM0301280,
Iasf�dlflrpktvbleirelllarrr'tr1.r.Cwrrn,Smile.d�rliUnc'e.IlfY[i1Gf;:N7C1 fR'trrllYr7 M.Atuountof,disinfmautu_,W7.
3.44'di u� (circrlwcll use}:
Water Supply Well: 7c.Sealing matetitds used(ctrccic all that ajlply):
❑Agricnittlatl ghlitnic p tlll'utili�- Q Nett CmicucGrout lid scrdonite chips or Pellets,,
17Cia:otlicrmal(Hcgti ngreooling Supply) Qltcsid;ntigal Water S}ipply(v.ngtc) E3 Sand Centeru Grout L7 Dry Ckt.%
.17hidnstriallConmtcrcial MeMdentbl Water Siupph~(shared) �.Concrece Grout O Drill Cuttings
❑Itti •lion 13 SPNially Gtattl 17 brave.
NQLAV;tterSopplvWell; 0 Bentonile Slurn, Cl Otber(cegm lain.under 7g)
Slvlouttoring l7Reco%an
tnjcction Well: 7f.For each material scleeted abovq proside antotint ef.tttaterials used:
OAtinifer Etecharge DGmutid%} (er Rentc4w-Lion
❑Aigui[ei Stonigr and Recovety ❑Snfnith,Darder
❑AiluikiTtst ❑st6nawaterDruinaee Bentonite.:251b ,Wtr:ga1.
OExpeiinientul Tcchactiq v ❑Subsidewe Cow.wl 7g Prtttvide a brief description of thc'abarndmuncat proLL lure:.
I36eoltterural(CYoscd Loopy riT acer
�; ..-'� -
1.
Weothenual tHeatit A,'CooliugRetuml 00dier(e pour "'"'� lain under 7g). _ r�.,
1 .Y G,.(y .,.,
4.Datctv'eJl(s).ubaindoncd; 4i26/2023 MAY 2 6- 2023
SIL,WCHlocation:
Premier Tech
FacilityXhvnerMum RrOity IM9 tifapplic ablc) S.CertiQritlgil::
111,McNess Rd. Statesville, NC.28677 Yj 5/9/2023
Physical Address:Cih',-a id Zip �_wal C'anrr-a.tor nr wol bn'r.r Vim
Iredell fiv c;nl lr{•�lh�s fa!'ta,.I[too. y CerdA.•thAw Ow u'efl(sj was(were)ttl!flocloyied hr
County f'otcel ldCttl)Cie iUau No.(Plyj accohlance uqllr 15.4 'f=IC OLC;01(10.vr?C_02(W i 1.11 Cmis7iveduli Shawn ds
and dral ra copr of lltfs rccordhias b,eeir Provided io the.ti•ell owner.
5h.>t:ttitadeaud langitudo in d4Tr= mIrtutc91scconds ord ximad degrees:
(if,*01 rwtd,q[n Iaat'IDag'is$tttic�[x) '7.Sito diagram or additional well detaUs:
You.may,use Uw back of this page to pto%•ide additional well.site,details of%cell
35.758011 It 80.79491 �V abaudountetu details.` You nray also vlacti additional gtages if itecc�csan_
d'o smi[nw,4.I1vwp ci't;WELL(S113EINC A11,013 NIED S>RUIFTTAL 1NSTRLiCTldAi5
Wadi%leb CarLYrrUdidu fi'wrd(ja if urtiitwle ll r m![hiple byecfitirt nr rmn•u'aref xupplp
rr'ellsQh[LY.n1rAll.}SVM��st�rstrce!!ii!r%ulnrrehnm��n!I_ayrtwur Ifbjrilcar:fanrt lqa; For All Wells: $uhrnit,this faint%sithin 30 days of completion of well
6s,Weil[D#•TMW'3 ahandonmcal to the rollow�ii►g
EIhialaa of�Vutel'Rcsumtire J[nfotmutiou Prtic�singi IIniC;
61r.Total well depth: 18 00 I617 Mid Senice Center,.RLrleig;h,KC 247699-1617
1lUb.For fide tlon Wells: In addition to sending the form to the address iu IOa
6c.Soveltolediametetr:l (iu.) aliowr also sublH.U.ctne eapy-of this.form%%lthiu 30 days of completion of well
abdudounietat to the follaw•in8:
rd.Water to vcl bcfo%t grountt sttrtact (ft.) DiAslon of Witter Resoureesi.Underground[ujecdon Control Pttigram,
1636.hail Scnicc('enter,Raleigh,XC 2769I 1636
6c.Outer casing;length(if Imown); 8 10c.-Fnr Water Stinnh IS tnicetion M.11s: In addition to scoding the form to
the address(es).aboye, also submit.one copy of this fount within '40 days of
completion of well ahandomnent,to the county health department of the counl�,
6f.Inner ca+sirrg Jtnbing;length of l;•nrre•n): (ft.)
wdmcrc ibaridmied.
617,Screen length(if knoll n):10 (ftJ
Farm GtY-3rl North CaroUrn Dcpartinem afEm iroautcnt aryl Natural Resowres-Division of Water RcsourRs Revised August 2013