Iredell_Well Abandonment_20230626 (5)

WELL ABANDONMENT RECORD For ImmialUw- ONLY:.
This form can be used for single of multiple wwells
1.Wcll Contractor information: �NMENT DFTAIL.S
Stefan Smith 7a,Number of ivells being abandon Id: 1
Aw c1t't.otlrictar tiatitc(or uvll oalir Ixrstucdly:aU9mlanl[ro a FI.0 n]tic,'I;r Ixopcny)
rm' rr,IJr,ple rqec!imr or c-oa-[rarer sul,ph w fls ONLY rah dm .wme
' CYi,crrucha,trsfmrdc„cn,enrr�tv:our surem,r ra'w jfara�i.
3576A
Al.Approximote wrlume of water remaining;in ww•ell(s):
NC 1VcU iTo imclor Ccrt ificatieu Nnmbcn
FOR R`ATF.R.SLIPPLI'WELLS ONLY':
SAEDACCO Inc
Collivany Name 7c.Type tirdisinfi clan[u5ei1:
2;Welt Constitiction Permit 9, WM0301280,
l�_dig}4rrjt}si'r(:Lli-u•ellp'ur,Mi,'.r.(i.a'.Cavrht s4ai AAdrxr.bff'ftfir,I,,,efc Y lfbiawr, 7d,e�[nOttnt of df3inl'Cet.int used:
3.Wrl[use(chrd:n'cll use):
Water Supply}Nell. 70:Sealing III atcri;ls,uscd(cbcck all iliSt npplyi.-
❑Aerfcntturvl ❑httmiciptllPttE?tic. ❑,NcatCcnicnt.Grout. Rx 13critonitc Chips orPellets
13(3rothcrmal(Hotting4,000ling Supply) ❑ltcsidrntiaf Wairr Supply'(single) ❑Sand Centegll Grvid ❑Dn-Clan'
❑Indusdriall(.ommemiat ❑Residemhal Water Supply(shared) ❑_Concrete Grout ❑ Drill Culling}
❑ltrigation ❑Specialt}•Grout ❑.Graw=el
Non-Water.15imph•Wcllr M Bentonite5htrR, ❑-0ther(explanmder79)
�lviottil0riite ❑R(Y:Ow'c[w'
Lnjerticrn�Yctl� if.For cach.tiratcrial selected abawr,'prtinidc anrourttof-tn;itcrials used:
❑Agtifcr Rcal>yrati;, pGruidrdww;der-lleutediutiara.
DAgtiifer Storage aml Recovers- I7Salinit_i•Barrier
Bentonite.:251b ,Wtr:gal.
�AgatifeF Test �Sitimm'ater Urrtfrtiigc -
❑Experintenml TixAmology Mubsiderce Control 77,;Pi-[n•i[lca brief d6xiiptian of the abandonment prg6edure:
L"iGecttllemral(C[osed,Laap) UTracer
06cotherutal-(iecltin 'Uoolinr Retani) CIOdh:r.(explain under 7a) Pour
. ••:!Rs AO�S.:s�4/26/2023 J
J«Datctt'cll(s).abaridnned: t Iti 7l'n
23
Sa.Well lucalion: L
rl-.i
Ferti Technologies
Faciliiy/CiOwrNam FxilhyJIDN appli~�tilcp fi,GertiRcatlob`.
111 McNess Rd. Statesville, NC 28677L4
5/9/2023
Pltj'sical Address,Girl,and Zip y, Illre_-!!l Cv-'IiBM Well Crpurj,:Iar'4r'W010mur D;ttc
Iredell 13[r sib,*Jlf11i.111f3 frYJ'171, 1 Jiernby eery r�'111n!iTle tre11(sl tr res(uerci-r?tirrruleatic l`fie
Cciuuly flee]ldcmificlilhtnNo.(PI.Ntj Cievorda,rce ldrllr IJ-A.,'C.jlC.0'C,(1M.or2C.V200 iMell Cklms4in- on Standi,rls
irncl dra(.a cop)'af'dd.y,•ccorcIhay he'en prrn4ex llo dre, ell Ciwnm
Sb,h§tihrdc and lra[igitut[a'in,ttcgrccslmiriutcslseconds or decimal ticgrees:
(iftlell ebb[1,mre fil0 o it I -ei:rzi) 9.Site diagram or additional vi-ell details:
1'6.11 tnay'iue tlt„bask of this page,to pgoyide additional well site details.rir-ticell
35.758011 N 80.79491 .W :tbartdutn►t2id>ietafls. Yiwti[naw'alsir';ltfach i[Iditio[ral p ides if rtecrss3n'.
CONSTRUCTION DETAILS OF WFLL(.S)BEING ABANDONED SLIBM1i1TTAL TN,tiTRLTTif2
Aflat}?trill cirr..vtrtlCj'Mq v.LV rws(arizi& t. ,hrir irrLlGpre byecHart tirrvsa•irarar rrrpplP
welik'ON'LYi0r,hat,:!.uUiwtt?[5rt7,t'r,UiN(LrOith7rltataLJUV call mblallo,refiornL, lga: ForA]1WdI—,° Submit thLs fnmt Within 30-da)�: of.cornplction ot`well
6a.well IDg:TMW-3 ibandcinm6i to(hc fpllowring;
Ilft•idun of WaterRmlurcm,Information Tpulcming Unit,
61►.Total well drlitlr:
161.1 mail Scrwiee Center,Ra1cil ti.NC 27699-1617
18 (ft.)
tUb.Fur Tnicction��Srrlls: Li additiitn lo.sa:ndi[Ie'!]t�form to the addfes's.ht lff;r
Gc.Borrbolc diameter,l (iu:} abate.al-w submit ooe rapy of this forni,svithiir'30 daps of eontplttiioit of hell
abliddoument to tile•110ljowrirt.":
I
Divisloti of WiiierResoutres;'i9iaderground Injection Gtrutriil Program.
Gal,Water level helon•.gr•otmd surface:. (ft.) 1G3C.Mail'cr%ice Ccntcr,Raleigh,NC 27G9')-Iti3G
I[ic.Tar'Water 5trnnh if-. Tnicrfion R`rlls; In additian to�axlin the faun la,
C,e Outer casing Icnrth("et latoww a): 8 (ft.) the addresses) <bok'e" also stibmit,otle 4), of this total ww`ilbla 311 days of
cor[iplctinnsof wvcll abandomncm no fhc chanty healtlt department or the court
ww"hrrr abardon:d,
6C Innercasiny/tuhing leni,-th(if lmown):
6g,sereen leuigth(lf lmowi u):10
i
Forna Cr1'140 Non CamUm D turun_m of Environment and Natural Rcsor.res-DIs ision of V1mcr Itcsonrc•^s Revised August 1013