Iredell_Well Abandonment_20230626 (6)

WELL ABANDONMENT RECORD FoTWuntallsc'ONLI•:
This firm can be used for singte o r muhipte wills
L Wen Cotitractor.information: 'WrLL A RAN DON 111ENT DETAILN
Stefan Smith 7a.Number of wells being ahandnn 1v1: 1
14re11,Cr1lYf1CY6r Nm ike rpv%teil owle pc'rs mien abindoiifiig t40ll.on I:L-Mbr rrpra{xni•) F0 rairlople. b farttolt w tiellc ONLY 6111) t1,e• a,7rlre
C'Cs143{ry(CG(dlr(t�glr[ifAffftU?1f,1'UN GCUf B;,Ii,Vltdr r�'Iv frliWl•
3576A
7b.Approximate volume of.water ret'naining in w'cli(s): (ga4)
NC;}heel CortirdoorCeitiffralimi t`T1 wbLT
FOR NVATFR.SUPPLY WF.I.L$ONLY:
SAEDACCO Inc
Comp"my Name' 7E Type or disinfectant used:
2.NVclt Constnictimt Pci,tilit g-., WM0301280,
Lf dlrli,t1tJlfk�Lfr.urll;nrlrPtr(ise-�6�ruV,S'CHd,J=arhLs'e•.LrfYitiou„�°fta rfd`nourr: 7d;Amount of disinfectant'used:
3.Well use(ehedi w ell.use}:
Water Supply ArVcll: 7c.'Sealing materials used(ehcck all iliat aliply):
pAnricnitniat ❑hluniciplipublic. ❑ Neat Ccnicnt.Grout. 5d Pciilonitc Chips or Pellets
❑Ci tlicnnal(Hc9tinpVoo1iu3 Suppl}`J ❑Residential Water Snpph•(sing-lc) ❑ Sand Ccntepl Grdiit ❑ Dry Cbn'
❑industriallComnicicial ❑Residential Water'Supply(shared) ❑ C6ncrete%Grmn ❑ Drill Cultiugs
❑leer tiara ❑ Specially Grput. ❑ Gravel
Non-Water Supply Wcll•. ❑Bentotite Slurn, ❑ Other(esploin under 7g)
®lvlonttarilre• ❑Recover' '
injection�Vcll. 7C For each material selected above,proAde amount of.tttiterials ti"cd:.
❑Aquifer itcclmrgc OCirouitdi}atea ltentctliutian
!j Aquifer Stante�rurJ Ftecrn en []Srdinity Barrier
❑Aquifer Pest v l7Stamnt"deer DIrahwgri Bentonite.:251b ,Wtr:gal.
l7Ezpelimental Tcthnoloin' OSubsidelXc Culunil 7;,Pftni ie a Irrief description of fic.abandnnmcnt pntixdorr:
Ockothennal(Closed Loop) nTtacer,
❑Geothermal(Hcn6na,.'Cuoli)F Return) ❑Oi)icr.(es lain under.7•g)
pour
[.Date n'cll(s)abandoncd: 4/26/2023 �..�' l�` @_. s
s,a.wi:n.lgcuiti,in: J U N ti Z023
Ferti Technologies . d� ro
�.Certi.fit:itloit: Ind\'Y{�r`i✓41m i "+. nY.4'�Ur"'ratil'rtylrlivli;r Naito: Fr,•ilitr lD,a of applicablC)
111 McNess Rd. Statesville, NC 28677 5/9/2023
Plicsical'Address;Cih;card Zip
Iredell 13j,vkjfirlg,Nus +rrtpt,.1 JiembTr celery<!!tnt the trelljsJ was(la'eYc}'a,5cutdearlcd in
C.isuii, I'zrrcl ldcntlfi<�tk:u No.(I thj c+C4CVn1CMCc a;!llr lJ:4.AC IC b;C,0100.or 2C.0200[rc•dl Cair,rlr rtctiura Str,ri<1iin;s
raid 11ral a cop),.of 7frfs record 71ats beerr•prnvideef l011re tivit amsucr.
56.i-ttifrrdc and i+mu itadc in•dt grccslminutaslscconds or di'sc1 141I dcggrcc.:
ofuV11raa;l,o1a111r`i:rp}i xid}lcicr7) 9.Site diagrainnradditionalwelldetalls:
�'ou rainy-use the bkk of i 1bis page to provide additional Well.sire details.ov crell
35.758011 N 80.79491 NV ;ibaridotu►ientdetails. 'ou taay&attaeh addiliollal"Kigesifne-Cessary.
C ONSTRUCr10N DFTAIl S OF WELL s)REIN(;ABANDONED VURM TTAi,iNSTRLTC'TiO�TS.
�ittrxlr H�11 eirr..slru�t7+rr;ta!txver't it•avrri1ra51e. 'Fair'aralliple ii)eetiurt ru rylrl-water sLPlali'
irx11S't)YL}'tr1r11 t is dal.aid{Y?1c111T/tttt:'r ILCUrth7J7C1 Tlt,fa C'�tt Svl t(t OhA�srim. 10a For r►ll Wcltc: Submit flik ranee lilthln Jt)day'S of Canillletl0rl of tiL^II
6a.Well ID#•TMW-4 abnndRnntcnt.ta th4 fplloii°inG:
Division of Tenter Rmt)iircm,luforrnation'liructssing[snit;
I G 17 Alji1 Seitiicc eentek,Ralcigti.NC 2769-1617
6b:_Totid well depth: 27 (fIj
0b.:For infection Wells: Ili addition ta.sendirtg lie fontt to the addres4in 1Gia
6c.Borehole dlantetew 1 {iu.) above-also soblldt one.ivpy of ibis fonn.msithin,30 days of eonislteiioll of well
abiindountcut to the fallott'iug:
Division ofAiraterResourees;'Gnderground ItilLetion Control Prtilf,11A m.
6d,Water level below ground surface: (ft.) 1G36 Mail Seniec Center,Raleigh,NC27699-1G36
loc. ror Water Sirmth•&Ink-etion Well%. In addition to sanding the form to
fc d)utcr casing length(if Iolon n): 17 (ft.) the address(es) above. also submit otie copy of ilds, fonli within all dins of
compledon-of,wc1l abandonment to(hocounly licalth departnicitf or life comi5y
n-licrc oboiidoncd,
6C Innrrcasin,ftubin„,teni th(if l;nuwn):. (lt.)
6g.Scmen length(if knoii n):10 (ilt.)
Fami MV-30 Nonli Carotitz3 ihEnrun_.m aPEnt lmnutent and Natural Rcsoo.es—t}k•Lsien of Wmcr Iwsonfcc> Revised AuFns3 10 11
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