Iredell_Well Abandonment_20230626 (4)

WELL ABANDONMENT RECORD ForhivierlUwONLY:
This foam can be ils)Id far Sitigl2 or tlildtipla\~•ells !
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t.Well Contractor information: WELL ABANDONN NT DETAIL s
Stefan Smith 7a.Number(if\hells being abandon Ida 1
Well(emactorK,ntciaruilnSerui�rwr�rll7ab5reiaydn8.�scil.5nlirllirpra{xrll rru mu(ripie.. frJect(ar w cvrJ-rafp,• ,irprvl' gilts C).\'L1' �rrL .Jt{ •su'1ir
rr�usrnrcnavaf oa7dniutJsnN.ivJv cn,r sJJf.Jnlr w+!a�r>1�,
3576A
-NC\Volt CgalrrcigrCcrtificaiiqii Nan hsr ill.ApI mmimate Volume of ii-ater remaining in well(s)-
FOR WATF:R S UPP LY W ELLS ONLY:
Cgn:an,Maine 7r.'ry'pc of disiufo ctant used:
2.\`ell Construction Pertnit f:;, WMQ301289�
Irvrity'Jld:r�'dL+utitlterm,r(i.i'.,Cuarrfr,S'tu:c,1'�rlurxi_Irrfrctinrb;rtr.Yftvruu•ir 7d.Amoutitofdisinfxi:lnluR41:
3.WdI usr(dicckw ell'use):
Water Supple-Well: 7,c:Scaling matcri:ilc used(cbccic all that apply):
❑Agricultural. I7htuiiicip7ltT'trblic. n Ncit Ccui4nt�mmt I>� 13cntOnitC CltipS.or Pcllc(s,
0(3i-otlrcrtnal(HcatinttlCoolina Suppl]v)' ❑Residential Water Supply(single) ❑Sand Cement Grout ❑vrp Clay
❑htdustrinucomnicrciat ❑RcsidentialWatcr$uppl-,(sluircd) 0.000u-ret6Giorit ❑I7ri11coIlings
❑Irrl'stioii ❑ SpeciativGout ❑Grivel
Ron-
��lratcrSupphvWcM ❑PeutaniteSluM' plainundcr7gj
�1Jig11IlUr777L ❑Rct:aren'
In jcct oln Well:: 7f.For cads material selected above,proOde amount of.materials used:
❑Aquifer Rcchviiee '❑Grauiidimier Rentcdiaiioli
OAquifer Stonige aml 12e€s)ven+ DSaliirity IIartier
❑Aquifer Test ❑5lormiratcrUrdircteti Bentonite.:251b ,Wtr:Sa1.
OEa irinrtntal TcYbnologr' pSubsideme Control Ig,Provide n brief description of the,ahrndonment liptiylure.
DGeothennal(C ,scdIoop) ❑Tracer.
116es7thermal(Tier(inR''(oolin?Return) 00tticr(explain uuder7,) pour
J,Datcti•cl[(ic).:thaniloncd; 4/26/2023 ,
5a �i`eQ,tucation: JUN 2 ` 2023
Ferti Technologies ]r.^.wV•'�, '
ti.:Certi6eatipii inFLTv�t u i s-.r.;�Un-A
P,ciiitl_rYlJiiier Nnir>ti Fa;.i1H}•117�(ifatrplie.�blc} t,-�•,,
111_McNess Rd. Statesville NC 28677 3 ` 5/9/2023
Plijvsical'Address,Ciij;.iudZip. Wig
Zredell ICJ mgnffq this farm, 1 hatr,b•t'certij,v that the rrcll(s}irac(were)abemickmed in
C,ourii� P J>ecl IdeidiG tt allo.(P14j itsrutrkir:rc milli 1 t .VC44C 0.'C,0100.ur•?C'.0200 I' ell Goirisll7/0im Standards
dnd dhat r).cnoir t F(lris recard has be'lur'prnvided fo,Ihe ie•ell mrner.-
ih.1 thudeand loirg iutle,in dcgrccsfinintrtcslscsmuls'nrdaciiim d, rca5:'
(itti It l ilJ;arr�Liu +� isirlrt �x) 9.Sltc diagraot or additio nal n'cll dgta[Is:
You niay,,Ase tli`tract:bf Yhis pdge to provide additional~gall sits'dd5ils.oi well
35.758011 P 80.79491 IV abandountentdetails. 1ounim,al:w"attachadditionaipagsif.rteec sarv.
CONSTRUCTION DETAILS OF\\•'FI,L(S)BEING.AtIAND6NFD 51iRN1r17TAT.t1VR_PUC.TiUNS
:lUuor srril,cr,rrrue!"r+_q:ra�ctrelfir 3!'ao-iuiluL;r. l�iir Jru/fyJie rJJectruu w•f:Jrr•IFCIJtY"rJ1pF'17+
urlL,"t7K!I'a FIG r!a s,auni r'tJerr,urwrr u+wrrka rt'Isrlr.iJu eratJ in;uetk ate funrr. UJa:For A11:1 eM. Submit ibis rams within 30 da)-s of.completion of tiral
6a,Well[Dg;TMW-2
abandonmcot to thcfollouinG;
Division of NVater Resaurces,Information Processing❑nit;
1611 Mail Scn•ice Canto,RalciZlii,NC 2.7699-1617
6b.Total lsell'detith: 25
10b.For Tnli`ctian Wells; In addidon to sending tlx.:fontt_to lie addiess in 10a
6c.Borehole diauictcr:d ul. abort:,also•submit uric,copy' of tLis'Faroe teiihiii 3q dales of cotnplelion of,well
t abatidounteru to the tollmving`
Di is(on of Water Rtsour&%Under�rilund Iiije tiou Cont6l P ram.
fill.W;Itcr let cl'hclon.�tnuinCsurfacc;. (ft,) 1634 Mail$deice"Center•,Raleigh,(tiC 2 7 699-1 636
6r-(Outer casing lenP,W"{lf lmon•n): 15 (ft:} 10c.Fnr Rater.jiVpl•4, Ig f"tom\\'ells: In addition to scoding the form ttt
ilia address(es).above. also submit.one'copy of this form within 10 days of
coihptetiou.af ts,clrahandanmcnt to ttic wtmt}•licalth-depArtniciil of the county-
of.Iriirereasing1tnbinA Icnj,Kh(if lmort•n): (ft.) tvhuc abandoned.
6g.Scree"lenxth(if knolrn):10
Fomr 6NI-10 'Non h Carolina Dcpnirctn of Enti ironment m-d Naturgt Rcsoumes-Dh,iskm ut\'eater itciourcrs Pevised August 3013
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