Iredell_Well Abandonment_20230526 (6)

WELL ABANDONMENT RECORD For lrrlannllUseONLY: i
This form can be used.for single or multiptrt.wells
I.Well Contractor Information: WELL ABANbf)NMENI`DETA ,S
DETAILS
Stefan Smith '7a.Number of wells being abandoned: 1
Wd14euracterl.arm. 4r well uwrs11 p aa1clly.uban:tanikr 4ull.oa fiisar r'proper/y) Feu. nnrinpk rtl fecunrt a.. rhea-l.i•ir(cr suppl Wells .CO,WLY wttb A. •some
eamo entaar omlatun rn.irrrr or si lilt atmj'i rnr,
3576A . . .
NC 1Vsq CamraaarCcrtificetion Nntl+cr 71r.Apprn:clinate volume of tratcv remaining in well('): (gal)
SAEDACCO Inc FOR-WATER SUPPLY WEL.1 S.OM.Y: .
Canaan)Nuns. 7e.Type of disinfectant hired:
2.Welt Cuustiuctinu Permit#:, -WM0301280, .
Lt+t'all ttpipllotldc iivdlparnri&(1.e_Camay,&i:Q.larlrurc+e.Bice iris4.rYci ifromivrt 7d.Atnonnt.of.disinfectant used: •
•
3.Well uSle(cheek well use):
-Water Supply Well: 7e.Scaling materials used(cheer;all that apply):
❑eAgricultttnil 17htimicipil/Public f,7.NGttC.cnrciit.Grout bi 13craonitc Chips or Pellets',
❑Goothernal(Heoling,'Coollug Supply) EResidentuil Water Supply(single) El Sand Cement Grout ❑,Dry'Clay
❑IndastriaLtomnrercial ❑Residential Water Supply(shared) • El Concrete'Grout ❑Drill Callings
❑lttiration •• O Specialty Grout 0 Gnwel •
•
Non-Water Supply Wdll: 0 BentoniteShiny C1 Other(explain under lg)•
181Munitorine. ORecovery
Injection Nell: • . 7f.For each material selected above,provide atm:motet materials used:
•
❑AijaiferRccbarge ❑GruuridnalerFtentediatinn .
❑Aquifer Sianige and Reccverr ❑Sulinily Dartier• •
Bentonite.:251b ,Wtr:gal.
•❑Atinifcr Test •❑Stortnwuter D.raittaie -"- . --
❑E reriuieutal To:latology OSubsideuce Corttnil 7p;Provide a brief description oldie abandonment procedure:
❑Geothermal(Closed Loop) ClTracer �.,�._,;..-,C
©Geothermal(11ettingCooling Return) ❑Other(explain under 7g),
pour S 'r .\-," —ii V •o, j
MAY 2 6 ?023
• 4..Date wcil(s).ahandoned: 4/26/2023.. .
Sa Well location: C 1 Q1BOG
Premier Tech •
Faeility/0ivncrNanro Facility ins 0fapptiable} 8..Certiflealioin.111.MeNess Rd. Statesville, NC.28677 ., YI 5/9/2023
Physical Address,City,-aiid Zip Sw-�:Iirrc 0:101 cd Well Coronarot or Well gwrar U;ue
• Iredell lit..naming-tins fit rrrr,.1 ltereby-eertify-that dire welts) was(were)rrhaudaned in
Co WAY b PwielliLnlllloilinii NO.(PIN) ' ac-conlalrto with 1. [.lCICO2C,0100•or2(7.0200ifiil'CoisrrurrlariSlnnchrrds
and Oral a cvp)r of iltis record lair been provided/a tire-troll owner.
• 5b.t atitude and longitude in de ccslminutcslscionds or decimal degrees:
ot‘son riolorwwlat,olI5issllnccierw) '9.Site diagram or-additional well.detaits:
35.75801180.79491 You.may.use the back-of this page to provide additional well.site details-or well
N . . . • W abandonment details: You inti alsa attach additional pages if necessary.
C()NSTRiICTlON.IIETAILS t)N WELL)BRING ABANDONED STUBMiTTAL INSTRUCTIONS
:Ittarn my!)cnnBtructrart recurilf.)i7 aiiriilrb!iL Pcir nruhtple oblivion w•ran•wat r supply
wells ONLI'u-u0 the avrnecwia acrton%atteiritirt)riant ion can iuAnril a eArm 10a: For All Welts: Submit this farm within 30 days of completion of well
6a.Well IDd:TMW_2 abandonment to the followin1,
Division of Water Resources,Information Prueesing Unit;
611.Total well depth: 25 (It,) 1617 Mail-Service Ceutcr,_Raleil h,NC 27699-1617
lob.For Infection Wells: In addition to sending the fonn,to the address in 10n
6c,Borehole diameter:1 pti:} . •abroe,aka submit.one copy.of this font within 30 days-of completion of.well
abaudauntenl to the following:
lid.Water IeF'r l.be[nn .Division of Water Resources;.Uudergrottnd'hiject(uu Control Prrigriim,
ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
Gc Outer casing length(if known): 15 • (ft.) 10c Fur Water Slimily.4_infection Vella: In addition to sending the form to
the-address(es) above. also Submit,one copy of this form within 30 days of
completion of well abandeonent to the county hnihii department of the comity
Where aba
6f.Inner casing tuI,wg length Of lmuwn): (ft.)
doned,
6g.Street length(if Imown):10 (ft.)
I
Form GW-30 North Carntlrn-Depanrrr nr of En-irorancal alai Natural 1 csoreTCS-Division of Warcr tt Samos Revised Angelo 2013