Iredell_Well Abandonment_20230626 (8)

WELL ABANDONMENT RECORD Forlrilo-milll--A-tUNLY:
This feirm can be used f'or'single or multiple wOls
t.Well Contractor information. ABANDONMF11'T DF.TAll-S
Stefan Smith 7a Number(if hells tieing abandumed4l 1
Well C,Ouramos Nat le(At(roll ORi!tf Imsatmd)gbai danht ucll rm hfi8ierprofreny) Fcu' raldripie 111lection tug ,,wra-,rider 'q j,v belts ONLY m,rb dra+ s,ao,i
c,ilt+rruGtJq'lr(,•kttrrrlrNlttic'P1t,lYlrr l il�I S;Ji4.:ld on I C f lrm.
,
3576A
7b.AliprYlxirnate yulume of)sutu remainin in ireil(s): (gal.)
hiC kycll Cq(rts�raarCMitifi:c=7deu Nnni6v�
SAEDACCO Inc FOR WATER SUPPLY WFAA1 S ONIM-
CQnzyanpNanis' 7c'f.pe4irdisinl ctantuicd:
2:Well Caristrncti011 Permit k:, WM0301280,
i.f:.r,dl,gipheoh?c urb;.vrrriGr(i.e.Cb�r+h,.5'l:�r�,}urrarrce•.Lp'e�sYiui,'„rrcil!/'Rarrr+sr. M.amount of 4li5infel'tanl'nStYI:
3.Well usi(eLcckwetl Use):
Water Sopply Well: 7c,Stirling inaterials"mscd(chctlt all that-;Iplify);
❑AAgrkulturil ❑hl(micipaVPtiblic.- ❑Ncal Ccmcn(Gmilt FX Rcnlonitc Chips or Pellets
❑Cr othcmtal(HcatinglCboling Supply) ❑Residential Water Supply(single) ❑ Sand CerlttIitl Grunt ❑Dry Clay
11Indiistrial.Conrm civil ❑Residential Watcr Supph,(shird) ❑ Concrete drout ❑Drill Cuttings
❑Ircteatiors ❑SP2631ty Grunt ❑Gravel
�Qp-�'s°airrSupply,�Yclt; t� BertoniteSlim U011ier(explain under 7g)
®A•fortltodne ❑kccoyrn'
lnjct`llpan'Well• 7f.For each material selected abase,plv►side uniount of.'ritaiterials mscd:
❑Agerifer Recharge ❑CiNlllidilillCr Rr:ntcdl:ltlnlr ,
OAnuiferstorage_alYl litic:oscr, 0 atlniiti,Barrier
❑AiptifeiTest ❑S1orm�iaterUr�irtilee Bentonite.:251b ,Wtr:gal.
❑ZxperirrteutaiTechuulner OSabsidetLcConttul '7g.Prrlyidrslirief&.wriptionoftheab:iudonlricnt.prtrcitilnrtt:
CIGmthentual(C(osed,Idoop) OTracer.
Pour_
flGcothenrtal(Fl ttine'Coolinr Rellim) 150ther(esplainunder7.q)
4.Ditle well s).abandnrlcd: 4/26/2023 I t D T2n2^~
• d ,r CLrLT
5a.NveII IaCatl(rn:
•r,
Ferti Technologies
r:rcili}�IOivrr3rNasrw Fa:_ilii�•3Dla tiftppli;.aiblcl 8.CCYtifi�c}ltioil:
111 McNess Rd. Statesville, NC 28677 1� 5/9/2023
Plts'slcal'Adkcss.Cite,acid Zip J nsC,.�('emilsed well Cd,rtnclnr UcW01 Chvn;r Uiitu
Iredell 13ir sis7.ini thin fm-ni,I hereby co,i y 11ml 11M wellN) wax t erq)�:rlhrrrrra°rir>r:d-tit
l'uueiy Palcclldcrgificaikut Na.(PI\) cco nke)i tv iN ill;"151.-Nt'ACO2C'.0100.0r fj200JUr,11_Cciris'lixtt'tiauS/crrtdrrrifs
heist 11ra(a cep)'of This rccorri lr+rs bet'rrl mvklsd to lies ivell ciis-ner.
56.J-41itude and lullgifu(lc in(tcfirecdlmimrtesl5ticond5 or decimal Ogrec5:
gif,vclt Cut 1,i,ttc ttrh,)�rg;cc,ttlsca,k1 9.,Site diatgram.or additfoualwell details:
You nim,iu®the fuel:of this tyige to'-provid6 additional call site Mails or Well
35.758011 1\ 80.79491 abatidalintentdetaiL;. 1'ou tuns'alsU aiaClt ldditiatial p i s if rkt GSSan'_
CONgTR1t(_rk)N 1)ETA I1 S OF WFU-4.11 BF iNG ABANDONED 4UBMITi AT.lNSTRUCTlQM—
_lttrrtlr t,ril cv�rvtrrtcJiar:ra+torrltsl if urtiilre4ln. ,l'vid-nm/riplr irafectiok,ir ir:rt-n4t:cr.rt,j-f.ii,.
ngll 0,ML ytr rrkurr.'itr) rrearrssrbmfl,ojreA,rirc, 10a: For All'Wells: Submit this fnnn within 30 dal'S of cdnipletion of well
Ga.Well lUi TMW-6 a1s indonnicdi.to the folloiring:
Uipisian of Water Resources,Information Processing Unit,
16 13 MailSci i ice Cr ntcr,IL(Icit ly h C 2;�G99-1617
61►,Total well delitlu 24 {ll:)
10b.lFor lniectian Wclis: In additiou to seo-diitg tlw form to the arddresi iu'19a
abo;i:. also'subruil tare eopp of this faml ieithio 0 da}s of cortinittiiolr of well
6c.Romhole dhuvctcm 1 {in:} abandonment to the falloiving:
Division ofli°afcrRisuurti(s;Underground Iiijm1lun Conttiil Pnogralu.
6d,Water[Li-O'belors grrtund cnrfacc. (fk) IG36 Pstail Service Ccntcr,Milcigh,NC 27699-1636
I0c. For Nat�S(Innls& luiection��,clis: In addition to'scnding the faros to
6c..tl'uicrcasinglcngfh(iilmown): 14 ( ) the address(es) aboi'e. also submit'one Popl• of this'fomi within 3R days of
cotnplction:of-ii-cll abandonment to iticra(umN.health dep.mintctg of file Lotior
6t Inner casin /tubing,length(if known): tip) triers ibaruiQry(I•
6g.Screen length(If known):10 M.)
FO fill Cstl°-36 Nonh Csrollrn Detanin t i ofEovirun,nent and Natural Rcsoarccs-Division of Waicrkcirmfees lic,•iscd Augum 2013
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