Stanly_Well Abandonment_20231229 (3)

�VELL ABANDONMENT RECORD Fdi loicnW UW ONLY:
Thisfon C*be'n�Affif.siitgt oenittliipt wells'
1.`Yc[k.�cintYatwr lttfOrmutidn; WELL ADANOONNIEWDE:TAEIJS
I
Briin Ewing 7d.Numbe'refh,&sbein ubandoni-d
1
�VcllLoaltcacrorb•arfr .roriti�tta�>, ,1 > ttyxt,ans. ou.�Jl.utid iatltsi'praipeetyy Fa nrarinPh�. aryietfar tip
as}ra=utirtir alrPPA wolfs ONLY 'isub N,e wane
. _ .. c�;ra"sfrarcfrrua'eban�aarnaeirf�.)riry cmr,suh 4IJf wr�J6rsr,
4240 B
7I1.AiC Aliprn�tnate►•olninc n f*0W r einamik-to N el16Y {h tl.)\Vc11 CoulragorCvitihortLiau Nnirrbcr
SAEDACCO FOR SUPPLY -
r,
Can�tanl Naalrc 7c.Typd 6(dishk0l. ant utc.
2:Well Coustruct€on.Penatt d:
Il3tiffltrfta}flaYlAla well�RPiOWiiia'Cr�nry,$n:Y Yrariiinre..Iir*rrtfun.,,r7ep6sruwra . . - -
• 7ii.Atnounraf.disirifi'reant ttsed:
3.�Fellusi'.(c►1'ecl �cli;nrej: �: .
watcr.Sulipf,Well: 7e.Scaitnh ttcot tls u d(et>gct;all that applyj:`
f], luitlttil;it . I7litiantetlr tUl°ilblic. 1�;Ntt Ccniesit-Giuist. Rcntaaiiiic Chips ar f'�Ilcti
f]Said tenreN d"iltiut f7 D Ct?t°"
I7Gco 0mvil(11Gatin t<ga3lin�$trpply) pttcsiilelatltA[t�atet b`iippl}(siriglc) 1
ObxtnstiiaUi~oluniettial D[tcx€dcntial�WntcrSul}Aty'(sf>gied); ❑ConcreteG Tout
~ O:anllt it'lliogg
�1f[i `hall 0"sp wt}bwut t3 d1t,eI
I lan Wa(cr.Sitlrplv`h'�lC ©HentgttateSltttzy a 011icr(c pl6iunder7gj
>g1141outtgdng._ dRecotetj
Xnjcctton��'cil;. 7f.igor.cacti'ittdtctt -1Cctcdabort;piosideamount of.materialsttsed:
DAquifq...Fharge 17 mniidit�le licinedlat€pri, Neat Cem.:4'71b_ ,Wtr:3gal. Sand.Cem.:lb ;wtr:gal.
C1AgnlfetSonlye.uuift�rit�eiy LlSalilitv�alrlet , .
DAijuifet TLit nStoimireiter Uni€n;t
}7Ea'p^t€>i€antai Tectiyotc�tiv 17Sidrsidence f otttrnl 7 . iovideu htief description of EUc alrinrGrinmcnC l:rjeeitilure:.
06001herilrtl{C(ascd Loop) mmcer-
TREMIE GROUT FROM BOTTOM TO SURFACE
®G06t1w1rmal.(liazititto cook Xtetum) 1301her j Wtt undee 7gt.
h'
4.Oateirll(s).4Wndunb(l:12-1-23 r riF(' 9, 4 2023
;it.�yeii Within:
Residential Property
racilitpJQ7lYrierNamc" _ Pxilityils.(E'ilpplicabldl S;Ceriiftatpfligtt: ;,
25384 NC-73 Albemarle","NC 28001 Hart. 12/7/2023
PkySicat-Addrrss,Ciiy;aiidZip Sr-AUNnr4of04ii w%V411crirfra�r:vr..sXlti),N Mile
Stanly ttv x!,zla Ibis• !liens !
fry ts; ;�h�4 by eerPlfy�•(lanl ti}e uelt{s,!>•rws nsem)ahcnarlOner!rre
Couutj 1'�necl.ldaef3t"rrttluieNo.tPl6]r arcxoifrtrce ntidlr t�:iC tC,O'C QIt?IJ;aroC.02Qtr Telf Ceiaasrixt4farai Sranrltirds
arrirlllrcrt acbpjcatllris rep
rd liras beeiipaviarerlla the:tieli owner.
�ti;; atittideandlan�uccoiti,ctc is7isittlutcc/scciinds"vrdcer�irildeli,ces
(il�tetl r".etc1;itua t dllotrg is<irlrlcirr�) ?.Situ di.�rine err atddifiou.tl ttcll il��ti�s:
You silo} use the 6aclt pCtlirs page to pto�ute'addili4aaal Rill site' fails ae�w11
A' �W,tlaaudoilntettt dtads°S'eu cnilS at�t:.�1�ch:uldittuuati� s if ttecessiiiy.
C(D1VgTRlIC."no1 .4:D1'!'A,tg-q OF.A r'ELLtMb"BEf�CG"AiAh1DC}NED SURNITf'1'AT,iNR7lfl=N.5
' :PfIQLI7111NII[Y/lLYal7rCa({rYlKLriI•l(3,a�0YYIIIQL� /cirmutnpPria�erctlwenraayn.urarav�a•upyh. {, .
adds OhPi l ri#ali f7,r sia:a�c:avnstnxrta}r•Sx4iurch t i}rrit,i r}n can xiLirift wWIWI rs ![ld: Nnr All:� ctt, ua►ni(-Ih�c famt stithin 30,daYs of cotuptetion-of well
Ga,Fi'eGl II1 �MW-1_A �btEtulonmciiYtts tlrs tclld�t€tt,:
€iiSianofWaterItestlur�;f4omjat€ n,IPriicc.&4ngUnit;
1611,16d Sceti ica enter Rvleit li Ide 216 J-fl6l7
6b.TotaliFeUlcptb: ao (rttp ,
bqb.Pat 1 €ectien t'4''ell9: hi additioa to sa:tulfag lled,l•oratt to the address€w IQa
6c:ltoeo hole diatttictea:2 aliovc,aLw'soil o binne copv.of this form�tillaiia 30'days of cam.PUnion of 401'
��:� i1b11udiinlncnt to tiC,folloR'€
Qa='
6d:�Yatcr tct:•+:i:bafon,iyeoasnt6 airfaece (fr:) .l}it�lsiatti,at Vi'iater Rccoittlecs.Urtdergruuiitl:6ii ja�fou Coittral E'tro�eatu,
1636[%6;11.t"igC d`etitir,itala:irtr,ll( 27699 1636
r
t ,
Gc..Ootct a asin ienglh.(if lmnrra): (fG) loc:Fne MIS'*Sarnnll Rc la![rtinrn��It is In addipion tot wimling the fOm:to
We.5ddmss(es)'abo ve, also suffnu(one. copy of this,Ibttn Wiliiiii 36 days of
eornptet€an at'%ve14 ali' donni CA Itre county.heafth,dcowinicrrt of the cony
Or.Lan&ess n� nlAn;-1610h(ifl arunn): �vlurc tCicttiiloncd, 4
a
f
6g..Ste&o,Icugt[t(If(aiot!'n),20 -A)
R
Ron GW-10 Nonh CawHna Depatowra of Untlrenomot aW Nattuat Resowucs-DIvislan of Water RcsOums Revised Aft usa NO

l '
NV:ELL ABAIYD.ONMEI T,RE1CORD >atl�l��,tlu�oriG1, �
This f6fin caib bd used,156i ijhi;4 of tunitijik., W
Y.�Voli.�intrairttso'InfOetultitfa: 1�b:G[,A�;�NIIfbRThllE1V'C DE:'CrtiQG.S.
Brian Ewing 7d,Number a1111Y0Lti being Abandoned:
-1
15Tc1t Cas�raetorha :qrr►lloii Gsif+511 �liariJtisdi+;itill an liislll4'r"d cn frir, Rtulnfik. PIIfCrtt!ie a Arai Nr rhr ;v+r;pt- . WeIR. .OVL}' wNta IN, scum
( PC 5 pr p y 1.
Mead aiva'rbai''trJrrnevit,.)rirr ciare:x"M iit aa�jfirrn
4240-B
71►.Atiprnxitnate ouluine at.�r'atw•tn.rnitiuiin; in�i'clldisJ; (�ul.)
NC.�Vc11Co�lydctdrG:itifiwtaa+i�Nniubcr ` i
I:ORAVATER S.FIPPLY WELLS ONLY-.
SAEDACCO e°
Coar}ang Name: - 7e,Type 6(dislii(exta0t uieel:
2.Wcl(-Causttvtk'snu Paudt 0:
4.Ar fn 0t 1)! 0#10µ�n p,n,,Xt,�: .srG, Yriittiitie:Jirjrtttor�;r7e k fkeNwr� 7il: tiiatttit:of:dlsinfcstsutfitsed
3.4V,di:ps�e(cliecl��ctl:oze}n { -
�Vater 5nppf�ilTcllt 7c:Settling t►ti 1[enaIs i►sdd(0101:,'11 tltnt aPplY):
prl;rtcalhtuiq i]hiunic►p tl/!'ttB li W,Nrit Ccnicut.rsioat. : Q Rcrrtniiitc.Ghilis or Nilets
i7(ityjtltcgtn tt{I 3cgiinrJCot►lin,Stgsplg J d tcsidrrntint lV,pt'cr�)jp i}(sin�joJ L1 S,itia�Ccmeitt rout 17 Dt Cta}':
❑hidu%daI/0=nicrciaY oRcsidential VircrSupAiy'(sbmrd) ❑Coi►crrte`Groui _n'DciItCit.iup
171tti •tiou C1 Sprttioy. tvat [7 Graw
han-1►►°ater.SupplyWell PJ Bentotute Studay E3 O1her(er3►lainundet7g)
i�trtlouityriug. niteiutery
[njccttoa�Yctt: Ili For6aCli mate taI SCIt sled A1144vG,p16{iac:ttnownraf_ntatcrials.used:
17r1gntferkcclsargc I7Cinitindtj;tleilteeutetii.dtpn' Neat Cem.:471b ,Wtr:3gal. Sand Cem.:lb ;Wtr:gal.
t7;4ijuifer,Siontgc airti Reco��ery I7Sailiuity®anlcc: - 1:
d7Ayurl'cr T&A. DSlciei>j tivter[7natuage
>jC�tp:iitiieniui Toth ❑Subside»Lc Cotttitil
7g;Prdt idc a liricf dticripttgn aftbc-alf:indpomeat pt term.
arm
I�Gdothcrnral{Clo.ed S:aap) Mincer. j
TREMIE GROUT FROM BOTTOM TO SURFACE
®Gcothctunt(Heatig%'Cooling Mum); 00ttt..r4a lain under 7t).
�:Datcav'cll(sJ.nlrandlipctlt
12-1-23 L L_i
$d.Weli l 646n: _—DEC Z023
Residential Property lill'OTiF' PD hrt ,
ti..�ertl(letlouE
iQciluclOncRTNurtic C.xility[Dta(rappl,blet DMA06
28384 NC-73 Albemarle, NC 28t1.01 8p,an E '�! 12/7/2023.
I�Iiy,- Addrea,Ciil aa�Zip'
s� nirr dr �nirca�va�c�,�����t,. '4110ivn r U,pc
Stanly fty.sj�pab{a this fnrtrt,.f the iveN{aJ was 6ra?w}-abandoned iae
r aeiuy 1'rarccl Idnril3tY:atldit:N6.tPiRdj a cafiltraice ii•rth 15.4.N'C,,fi;02C A60 i r-X.020Veil CuirStratcll+jn 5tcariikircls
uucl arat,•a mpa,iaj'lhis rccurd lr{rs be eaa prot�u'aif:/ti lire.►ietl duiier.
5ti:]< td6de;,aad Pnagitud'e 16.degnx�slititttuti slscennd5.ar dscm,rl ttc�iecs ;
(ifavcll Cakl;orK!st!la,sg;is 9.Site diagram,air addltiouat u;t:il,6talls:
Yon:tuay use tlec baeti of Ws p;tge"to ptilvials addifii nal tat6ll.si6.detat1s:oi well
- 'n �Y abaudountetri it'a:tails:'Yau rrtuy•atsp:�utocli:uiilitiaual pates oP treczssddcy.
CtbNC!R11�1 IQ],�1[1Fs'1',ti1d (}F�VELLt41 BEINI�A6rlNDAIV�D &TI- it-T.AT.0,9T1kUCTEONS
' .-fltradr+�rla ewavaructiiira'rntrrri1(s/'iJ+avr>SIaGIL /�cir,#,ri,trialfr a:rjriudte ur'raon.u•curr sirppla i
irVlds thYL1'+iIUr 11>e bvuh c +rstracr aie atnsr tirrnrc7at•ware rcv nrf' 1.0a;•Fnr Al VVell _ Submit.IW� r6mt aiit6iu 30:dA}'S of completion:of xirll
6g.�VeIB tD�:Mw-iB .aliandiinuicatta'tlsv•t"allaavii�,
Divi*a of,Water Restlucatrits,Informatkin Prtice ling Unit,
6U:Total acell it title'4Q 1611 mail'Scn tcC er,.Ralcil li,itC 2?Ci9'J-16I7 .
_ .-
10b.Et Titlerlirsn Welth: m addaima to setxtig5 the form to the addra.'gs tu-Loa
bc.H,arcltolc diameter,2 kaw.also snbnth oae eupv of-this.form witlriif A aieys of coniptetioir of well
nu'J' aibpadduuieut la Ilse,follotiiu�: ,
Etivisiori,aft'rirntcrRisoncecs;,TTirdert rtiund 1[tijcettpn�oitittvl Fox-graim,
6t1,Water IeFcl.:nsFota'gt oteatd QlrfaCe: (ft-) L636 tli:ril$ecvice,C enter;Rdldgb,Wc.2709-1636
p'n_��':etcr Simnlr.•.tc.Tnirctnn�'eiBA; 'I»ldtlitioo tv s�r►ditlg the feint.to
6c.:t}utcrcagingicrtrdit.(eEl rnn`vrr); tfw) llte:adates"es):abo�e, also sutimit.oiae-copy of this odu Withig 30 days of
canriptction of i4e11 aliandoanriane tk the eounly iseattli'dePitrinterrt of the course
6c[niter cirsung. ii line atxtral.ncd•
,,,/trrl►inl,tv�rt}r<Ir gif J;nuvrn): Ott) •
j
6g.Screen length.(If ku0rtrn):20
P6mlMV-36 Nanh.Carv[lin 1?cpnutucm of Pn4 irpmrncnt nsxl.lJarusat Res4+uccs-1?It lstonof Waver RC�eiuns Revised A4,usi 20t3.

f
WELL ABANDONMENT RECORD �( �arli>lemait�seoNtrY; � '
` ''tlusfamt:caiiibettsad;forslttgteormttUipGz.rtellllfs=
@,'lYcfl 4 Qutrateioc lufvt ruutiop; IVRLL'AR;t►NDONhti��11'£DT1°AM14
Brian Evrin nit univl:.l
Nc1[f`oue?rsu�n`�nr�.(ocie�llu5ru ptq�f��lly.�(�7uifluine�tititluriliml rutienyf.. r�ru, rwdn li ii!jov ar "or Rom-iiftfer sii�pfl wells, QVLY 'iattlt I& -srnuv
eDttisrrircrtotrrmGarriama it,anrrcntrs7ttu{rlfrixi.J6enr;
4240 B `J i?U,Aliprn�ittafe tniniiec of i*A inlialnink W�i0W..
NC 1t'e11•CoMraclorCoit(t'icnliniiNuit�aci �� - ?. _
SAEDACCO
FOR�W�tTVRS.UVVLYNVJ GMS:OhI:Y:
7G Typenf.dl�infi'etant u3eil:
;.,Well Construction Pettnit ,
. - Ld3t trlirijiliflrx+kf�well}asMilr(,',!"Ci,,ure¢.Staii..d�arl�uree.L�rt�'aft c�7el�keruwrt: •
7d: 66n nfoFdliinfictanttiswl:
3.`Vdl u (�hetl.wdl usej:
j
wAtcr 5apply!Yell -70:Se469 troWviufs usm(obeli,all that appiy):-
L1AS#nivait - phligiiciptl/pttblic. d,NatrCemctid;GtouG Uctitdriitc:Cbipsprt'ellcls•.
IgGe4tlecmt(&lcatit►,rJC+?cllt>a Supply).. . Gilicsl dent inl t4tater• 'uPty'.(51ngIe1' D S{triit Centepi Gttiut { D:Dt}GLi
171ndusttfab'Cgmnicrcial` MtWdential'Water-Sitlap4gsliamd); n Ctincte(u Gr®ul r-LI;DtUl Cuiiings
171ttt lion C3 Sp ctialt}Grout: d Gratl
1lhu llratci Supply lY ltg ®Ben#omte 5lyitx CI Other( gala-under'?
llahionitgiiug= CIRteo�•en�, R
[ttj¢cttan Wc1h 7t'PoecacU'ivaiterlaFselacted'altore;pieradexmoa®toC-tttntesials�tsci8c.
LletquifGrld cGar e: OGioginiti,UerFtentetli.Itipii'. Neat Cem.:471b. ,Wtr:34al. Sand Cem.:lb ,Wtr.gal.
C1AgneferSiomge it>rlRr�i:n`erj' �Sslii►iti 13,tttiei`
•l7Aijuifei Test. �Siijiruirntrr[liiftts�e, -
. _>jE�cpertnurival Te..L�[o,� []Sul+sidettr`Cou9Nl ?�:Pe+i�'eclu st lfri�di'scriptian of tlf��ubaatEpumcnG pa+tociyltires
fGeot6emr►t(ClosedLaopy �ITsJCer TREMIE GROUT FROM BOTTOM TO ,SURFACE^. " i
Mkbthcrtaatdleadg 'CooHugRctum)' ®Otkrii:.� lbittunder7:t).
12-1-23
.'Ilatc,iv�etlts}:at);ind4net6 � DEC.%,.
5a,lV!"tuerlt 6's lit�OT�'?"t`n fir�;.t9QA:t4�
.!rz'1Cn
Residential Property i
S::�erlvQcadipies I.
FavilhFlQhwiicrN�utiri� TxilitviDstiEappL;able} -. ,: � .
28384 NC-73'•Albemarle, NC 28001 , ria fv1►t 12/7/20.23 .
Physical'Address;Cit},'andZip stghtrc�arceiti�ledW�llCot4c+tti+vd;l,.,tfC7lctxr I7,te
Stanly _ 65280i490612
If} n�itr�tftis.fPnm 1 laetsaby tnr tfte iieii{`s}a-us(toera,F m5rarrfttrrEil irt,
rcc11iLlijfflk4tlnit No,(PItV atct�rnFtrtaic rv(f1a 15z1�ru1IC©2G'•Di.OD ur$C.U2C�t T6611 Cofis7rxtrlivn.StitiiikMIS.
.. � rtrtil llrat„u rnpt�.e�j1•tlris record kash�ere proiie�4�rlfallrei,ti•e1T ou ater.•.
Stt:.1,adoidemid longittnioin degrr xlltiittrtVp4st;oWs:arde,dmll del
(il:,t�Il t4td,a>,a l it r�� s iuttc�er�) .9.Siw diagram or addltiou;il v�cll aetaittsr
35.3638555 . *, 80.2609493 Yau.nlaj use Elie tiac}t of Uus pz it,to`pro}•irle:additiQrtat ts>rll.site.detatls:or csell
h lV :tbandotugr ttidetails`You tua}atsa;nmLhactilitiouat[xi s if tkce ley: '
Q`CDI�rt l Rt1C'i IQ)itt.tll't, fi S f)N IV LL(S)'BPING ARANDQDIVI't� Sf1Rli1Ifi AT,1111STRt1CTfQNS i. .
tUritit Nrl!enrratltrcditltr n[wxY,�aJ'Sf pvrtllmriri ["fir
uruffif{lr hJarirlte ur imn•nemr evah'.
xxldr flT±rLb'irtth 1I�pvtir�coarafr+acriruJof�rvrrhirr%ertL iuu cprr arLircr!wee/irm.
iQa Fur-All lVclt<r Submit't1St<s Fami'tiitt»n 30 4j of corupletian of UVII.
G5.Weil ID#:MW-3. �b;bndattmsnt ka'tlre t'vllaivitir-. �.
. - [II)'Islan of Wutcr Ytesupt?c�,Infor¢ratinn Pruecsring 41nit,�
6U.flatut ticll depthi 40 1 GI71ltiil Scrriec�critec1T:ticity NC 2?6J9=1161?
Iltlp.Tor Ttilkow,Wells:_hi 9(wtioq to krldiug tll fotm to LU addtr ss It 162
tc:l3at�kofe dlatnetct:2 �u;). *ave;afso submit otte&p>. of this Zomi n•itlitir'30•_days of cornptetioa'of.w4ll
tlbiitfil gbnent to tlic fall •Int�-_ j
)Qiuislon oP Water Rasoarces(�idudcrgruund LijctKiun Coiittvl l�cti mtint,
fiaD,+iYlaiti a teFcl.bei0n opntlsUctttccE tft:) j6"t► it m ce l enter,R4 ci�_f,,NC-2',699-1636
6c..Autce•C;isin�ictr�th.(iE lmnrv-n); �f�) 40c:F�gn Watcr Stmnls•-.�r ldlertinn lVeRa:. to adriition td�nditt5 the fattti to
(he:addtess{es),aboie, also sulitnit.6ue. copy of tl fbtnt tvitlih o days of
Conipletian of tell ahamioruaent to ttie carom}•itta@h'dcinirinrent Qf lire county
�tilirrcaitxtndtancd. i'
Gf.:Cnef&uisin�ltalii tr leliyKit(if lmuwn)e: (ft:) {
�ig..Screen lee- qe kuoMn) 20
i
Form G«r-a4 Nonfa Careflrn 17cp�nrncm o!ErrL4rouuKsrt alat Naturai[tesouares-Dit istan of WatcrALso I s d cv mcd Augu!2fJt3;
' � i