Iredell_Well Abandonment_20230526 (5)

- WELL ABANDONMENT RECORD For!Mental Use ONLY:
i. This forni on' used-for single or multiplo ties
I.Well Contractor lnformatidrt i �jA WELL ABANI)f)NMENT RETAILS
Stefan Smith . . `� 7ut.Numbero€trt.•1Ls being aliande[ned:.1
Welreouraelor Manse,for bellanne pc13giL1(IY.ntz.7rnianin;oat On lii38kr'propcnyj For rmrThplc. intertlar or r.'on-itardr soppy, weds- ONLY with. II' sonic
rvNL ticeno'i. bondonineot-)Yttt Calf Sol'iilt nswfi roi,
3576A
NC tVeU'Coidreaor Ccniftatllau Ntin acr 7b.Appruzimatc volume ut water rieinaining.in welkin (gal)
SAED}1CCO Inc FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of dihiufectant tried: .
2.Well Construction Permit l , WM0301280,
Lill tdtl:tlilrlkorde lieltperriritr(i.e.Count.Stuns,YarlOusx_firjentfort.iPlei f.t),ublr7 7d.Amount Of:d1 infeetant uSC4l: -
3.Well use(check well use):
Water.Supply Well: 7e.Scaling materials used(Cheek-all that apply):
❑Agricniturit C IMitnicip ul/Pubtic, la Neat Cemetit,Groitt alRebtor nc Chips or Pellets.
OCreothcrrnal(Hcating,'Cooling Simply) pit sidentitil Water Supply(single) 0 SanJ Cement Gttiut ❑Dty Choy
❑hrdastrial/Comntereinl ❑Residential Water Supply.(shared) ❑.Conctete'Grout ❑ DrillCuItings
❑Ittkation . • - - s 0 Spectrally Gaut . O GroeJ -
Nou-Water.SapptvWell: - 0 Bentonite-Slnuy CI Other(explain tinder 7g)
®Muaitoring 0Recovery .
• . injection Weil: . - • 7f For each material selected'above,provide amrntotof materials used:
❑An refer Recharg ' ❑Grnundiiater,RentedLition
❑Attuifer Storage eiri Recovery DSalinity Barrier ' .
Bentonite.:251b ,Wtr:gal.
❑AiluiferTest ❑Stonnw•alerDrainage — - -- - - -. --- .-
❑Expeiiuienlal Tl httotog ❑SubsIdeticc Coninil 7g.Proridc a brief description-of the.ahandnntncnt procedure:
OGeotltermal(Closed Loopy DTtacer
our
' ❑Geothenual(1ieatinl'Cooling Return} 0Otber(explain udder 7lt) P -.,_,:—,, ..
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4.Date wcU(s).abandoned: 4/26/2023,
- MAY. 2 6-2-O,z3--------
Sa.Wen location:
Premier Tech �lTS,1 C':'d` C4
Facility/Owner Name Faeiltty it)s(ifappl;,.ablcl S•CertitIritlgit::
111.McNess Rd. Statesville; NC 28677 .- -- o t4 �J • 5/9/2023
. Physical Address;Ciiy,-alid Zip S- -Slnn Olin iI d Well Oniara;na or Well oisrnr Uale
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Iredell • By tgpinLg t/sMfirrvi, !Iieieby-eertify-thai the u'dN{sJ was(tcere)abandoned in
•County f:arclldanJJttcition No.{Plt j 'accordance with15.47:c 4CO2C;diOdor2C.0200 ffclf:coss.trucfiati Standards
and that a copy offlris record has been provided/.a the treat arson
Sb;Latitude and iongitudo hi dogrscslniinutcs/seonds or diwimal-degrcei:
(if welt faW,one lilt/hrng'u.sitntcier') 9.Site diagram or-additional w•ell,details: .
You may.use.the batik of this page to provide additional well.site details-or well
35.758011 N 80.79491 .W abandonment d'(ails.' You may also attach atiditional pages if necessary_ '
C()NSTR1iCr1()N.DE'rAILS OF WELL(Si BEING ARANDC)NED .SUBMITTAr,INSTRITCTIONS .
:Wade ireli cvrzytrectrut recrvills)11aririJFOGk. !•iirmulapte ufetainc or'rum-waterxZppte
treas.ONLY with Me slltlt-dvrrstreake--o?ramsbTnrat.I'trl rem zith,rtt7 one Ante. 10m. For All Wells. Submit this Iona within 30-days of completion of Well
TMW-1 abandonment to tlic following
Ga.Well ID#
Dlvlsiun of Water Resources,Jlnfor•mation-PrOeessing lJnit;
Gb.Total well depth: 33 (ft) I617 Mtiil•Scrvicc Ceritcr,Raleigh,NC 27699-1617
ibb.For TnIcetloti Wells:_In.addition to sending the fount to the oddress iu l0a
Gc.Borehole diameter:l abate:also snbritil one ropy.of this forum within 30'days of completion of.�yell
�u) abandonment to the following:
Gtl.Water[cvcl.before ground surface:. (ft,) .Divislott.of Witter Resources.i.Undergroand'Injection Control Pregratu,
1636 Mail Service Center,Raleigh,NC 27699-1636
do-Outer rasing length.(if Imntt n); 23 (ft.) I0c.For Water Snnnly,cc Iuft�stion Wells:-In addition to'sending the form to
tlte_addresses) above. also submit.one copy of this form within 30 days of
completion of well ahandornn:nt-to the county health depanatela of the county
Gf.lamer easing/tubing hthin tern h(ift5tuan• where abandoned.
.l g 1p ). (fi.)
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6g.Screen length(If know n):10 (ft.)
Fan t GW-30 Non!)Caroling,Dcpartnrra of Ero-irounicnt aryl Natural Rcsou ccs-Division of Water Mowccs Revised Angue 2013-