Iredell_Well Abandonment_20230526 (3)

WELL ABANDONMENT RECORD Far h0cmitlUscONLY:
Tlds fekit Tait be used for single or multiple%cells
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I.Well Cantraitoc Information: WELL ABANDONMENT.DET,ILL.S
Stefan Smith 7a,Number of well.;being;ahanda ned: 1
Welt 6urworNanti Qrii lluir,�r' u icll'ahaielri„lit ucll.iinliislltcroro cn Fco• rndopk 1geeawt a 'rr,ri-Sister supph' wells .ONLY wrrh hie' •sruae
f Ik 5�' P P 51 i.
±•orretrtrcfrwt'r�!'e,rda,unt�rJf/Yrrr eror,na7'lrift w1aJ6rr�i.
357 6A
NC NVOI Coatrador Ccft1rk [joii'NonbcT 7b.Apprnstmate volume of rr ttu remaining;in trcll(s}: (gaL)
SAEDACCO Inc FOR 1VATF.R.SUPPLY WELLS ONLY:
Coti>aany Nantc. 7e.Tytte of disinfietant us id:
2.Well Constludian Perrt..it 6:, .WM0301280,
lr3rrrll rrp;,ik�ble udlliar�iu7r(i.ct'CrLrth'.S1WC.burl ire.Lyrc'ti�in;,cic l;f4t,owrr M.Atuotlat of.diJlafNtaut'used:.
S.W.eil usti(ehecicwell use):
Water Supply Well: 7e.Scaling mutcA;0ls used(cheek all that apply):
DAgricnthttal pivlitnicip d11'ti!?Iic M Ncat Cenrctit.Giout 6d J3cntQnitc Chig+s pr Pellets
0(3eothenn:tl(14catipo.00ling Sloply) Oitcsidenti ll Water siuppty(single) ❑Sartd Ci:ntenl Gtnut ❑ dry CLrp
❑hidustrial/t_omnicicial ❑Residential Water la'npply(shared) ❑.Conct>te'Grom ❑Drill Catliin•cs
❑irri [ion ❑ Specially Gruul ❑.Gra%el
tang-11'atcr.$appl}1Vcil: ❑Bentortite SlutT• 0 Other(exalainunder 7g)
®hlanitodue ❑Recover'
in jcction 1Vctl: 7f:For each inawrlal selected above,provide:mtountof materials used:
❑Aquifer Recharge . ❑Gmund%6Wr Renwdiation
❑Aquii'ei Storage athi Reeoviro OS alinity Battier
❑Ailuifcr Test OStonnwa.ler Dlrs nave
Bentonite.:251b ,Wtr:gal.
L]Expetiuinutal Technology DSubsideixv Control 7g Prattle a brief description of the abandonment priJcctlure:
06coihernnl(Closed Loopl CiTracer
-,�. ..
❑Geothenual(HeldniWooihmReturn) i30dicr(esPlain under 7ttl. pour e �.:,_,•ya2
4.D;itc%Yall(s)•ahandnnctl: 4/26/2023 MAY L fi .
RL Well location: In+`c:; r- inn tFln Ci5�' :Q knit
Premier Tech
ras(IttyX7hvt:rNims Fmiliiv1Dstil'appIta tsl 8•.CcrGiflrttiait:
111 McNess Rd. Statesville, NC 28677 �[Y%� Yj , 5/9/2623
Mysicat Address.CitiVaud Zip 5w ali r4 •Cc it iN4 Well('a,urtoai ur WeII On m,r Uinr
Iredell fit s� icing t1i1.s frrrrt,.l tremby cirhfy'rhal the wellf's) errs(icerel ahandoned ire
County NiLcl No.(PIN) av vrigal ry willr 15.4::4'C..-1C 02C.0100.or 2C_0 00 I'ell Cwisfivc-Ouri Srarubirds
and ilral rr cepr of ilds recant bus beeit provided to lire well owner.
Sb.Latitude'aad Inngi-tu.tfe In degmslmluntes/seconds or d4'iwal degrees:
(%fact[rout,qua t;,Ulong lzsulricietny 9.Sito diagram or additional well details:
You inay.use the back of Ibis page to pto%•ida.additional well.site dinils'or well35.758011 It 80:79491 W abaudountent details: You amy aLso attaell aaiditionafpages if necemry.
C.ONSTRII(''i'O,V.DE'T.A1L.ti ONWE:LL(1l'BE.IN(:ABANDONED SLIDNIT1717Ai,iNSTRtiC.TiO-MS
:trlrxir trr17 eur�•raciim2 ricru:ils,)'1j ai i0arile. Fiv nrulr,ple iiyadqu cv rwa-iraier snfph''
welET ONLY u•rrh IN1sv,m ev,rsrnxxir,dsrmrchnVueru.i ua can 11hMI.wre fans. I4a: For All Welk: Subinit this fonn within 30 days of Completion of well
61.1V.0 IDL(•TbM'6
n@andonniciil to the folio%%'ing;
Division of Water ResourcM,lnforination Prucessing Unit;
61r.Total well depth: 24 (ft,) 1617 Mail Senier Center,Raleigh,NC 21699-1617
Wit.For inieetlon Wells: In addition to sending die Form to lha address in 10it
6e.lioe holc.dianrctcr:l (iu.D abaft.aLsu snbiadl one copy of this fonn aithih30days of Cumptetiou of[tell
abdudouniew lu the fallo%%•ing.
Gil,lVatcr lctcl.t►eton w ounll stufaec: (ft,) Division of Watrr Resourcesi Underground luiLct(ou Couni)l Prdgrutu,
h 1636 Mail Ser%icc Ccuter,Raleigh,h(;Z;G99-1636
Gc.outer casing;Icnrtlr(if lmown): 14 (ft l 1[tc,inr%V:rter Sitnnle'aC lutcctinn 1Vclly: In addition to scBdiog the fonn io
the address(es) aboi'v' also submit-oue copy of this fomr %dithin 30 days of
completion of%sell abandounwnt to the county health deparnueni of the county
(if.Inner casing . ltubing length if nown• where ah tndoncd
6g.Scr•ecn length(if know a):10 (ft.)
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Farni GW-10 North CaroHna Depuruvern of Ptn'iroompt as1 N:rural RCS41L•CCS—Division of Water ftesoWR'8 Revised August 2013