Montgomery_Well Abandonment_20240205

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WELL ABANDONMENT RECORD 46\ For Internal lUSe ONLYt• ' •
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_This fotnicatite Used forSingleUrtnulliple Wells.,
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' I.Welt.eintractor Infoririation: ' \L\ WELI.ABANDONMENT DETAILS • .
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John Eisenman . 7a,Number of mills being Mondani:ill 1 . • •
WellOrirractOr Nacre(erweliOWnel tkiSprianY atiartiOrtini well Oshisitter pfapcm) For rrodople ottedkor oi' 'ada-It .r: supply adds• ONLY will the somo
COMInfcrkNiffebilid011klallt,Itid(yin softoin Oirefiirm,
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4439A i
7h.Approximate%Maine of*atm',reirtainhig•in ivell(S)9• • 041.11-.)
SC Well CrintrattorCcnititioo Ranter
SAEDACCO . FOR wArpits!JIPPEA Wgi..t$ONLY:..
company/rase 7.Ty Pe erf disinfeetaid used:
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2:Well'Construction Permit d:,- ,Ltd iiiii/ipliodde:well perratii0.e.Olority,$tati,lietorice:brjortiom ottii.if kerma .
7d.Allmon t of&Infected used:
• . 3:Wgli u9e.(e.licck Will tvie)t ,.
. Water Supply Well: . . ' 7.e.Sealireg Materiais.used(elmeirall.thar apply):
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bAgricielnual. • • • OhltinielptiliPublie, . ik Neat Ceroctit rtittt, • El-Ber4onite CtrifiS or Pellets.
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Elbroilicrinat(Hcating/CoolintSupply) hfiesidential Water Supply(single) El Saltd Content Gmut ' El•Dry•ClaY •
. • ID IndostriatiCrimmercial 13Residentiai Winer Supply(shared) 0 Concrete Grout •
13 Dull Ciniingi
- .Eihrigation .• . • . . . -0•• PocilliiYOrilift ' ! ' 0.Graeel . .
Non-Water Supply Welt: ' .. . . •'' El Pentonite Shirty - El Other(explain tinder 7g),
IgMotiliorino OFtecotery
injection Weil: 7f.For'each material selected absive,preside momentaf materials used:
OArtnifer pedlar&. OGromidirater,Rentedlittion Neat-Cert.:941b ,Wtr:7galc , Sand Cem.:lb. ,Wtr:gal. • •
riAquifer Swinge aid Reetwety 13Salirrit Barrier
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- ElAntriferTest OStomrivnter Drainage
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, • . ElbrpetiettentalTechttcrionv EISubsidence Cotriml 7 litnyide a letkf ikseriptioti or the abandonment prkedurei •
ElGeothennal(Closed Loop) OTracer I
well was full of.debris lat surface, overdrill to bottom of
EiCeeothemral(Hitine/CoolingRetum) •ElOtheitexplaitt sunder 7e) • I
' borehole, then pump portland through tremie pipe from bottom
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4.Date sted(S).erhandoned: 1-3-24 of hole to surface .
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5m Well lueation: • •
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mullinix.Grocery , . • • •
. 8:Certilleation:-
FacilinVOwerr Name Facility ID,/Ofhpplicablc)
i • •.3079 NC Hwy .109 North Troy, NC 27371 1/8/2024
Physical Addaess.City.and Zip ' ' Si.0W7n77..-iliiii..e.4:1::=7tr?:•;,:r0-7-;4s• • Dam
‘'.1.- 4.,....-41W-.47, .1C--.J,...,:s74c...7•ri!-7 '..---'4.
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Montgomery . • ify signing ilue.:.!-.t.i."_,-...-4- lifr that the iteli(s)•wasiwore)abandoned in
Cauniy. • Pawcl hicailfs6alaialo.(PIN) nceorikinit wig)?1.:ii1 ICCIC 02.6..0100 or 2C.0200 fif-oll aitstruction Sianikirefs
and that a copy ofthis record has been pn*idecito the well:cnner; .
Sb.1.,:adiu de and longitude.in degrecsiininntes/setorids or decimal degrees:
Owen ritd,one.lat/hang 4:sta5l:Item) ' 9.Site diagram or additional well.detalls:
• , You may ilit the back•of this page in pros ide-additional well site details or will
. • N . . • • • W •ahandontetent details. You may ik*mach additional pages if nect:ssary.
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CONSTR1ICTION DETAILS OF WELL(S)BEING ABANDONED -SUBMiTTAI.INSTRUCTIONS i • .
...an-Dift trill.ro.ristir*kin n'iciFilfil 1 jimillf obtr.. .Pe.ti•niida;ple in)raiim cii rofinortuFr aupply .
treks.ONLY ir:iili the AIDlid roloirortion,a4rilaionere.jou tea substai oirestin. leal Par All Wens: Submit disk fame-Within 30 days of completion of well •
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6:1-Well 8rmw-3 • - -,.., .nbandrionieut to the following: - "I ,
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• 77 e-- ' ,vin-,, ) . • • - 1, . - - •
^-..,...L.,,,,,L..'. 4. : ''' ,Division'of Watter ftesoutmAnformotion PrOcrsing Unit,
./617 Mail Service Center;Raleigh.NC.2.7699-1617
6h.Total well depth: 25 , (ft.) C.C1) 0 5 2024 . ii
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Illb.For Infection Wells:•In addition to sending the loan to the adiltesS in 19a
. p,r.c.:Dord.rtf2,fttiAii.Asir submit one Copy of this form within 30 days Of completion of'sell
6c,Doreltole diameter:2
(In.)' inf3ri0,,,-. ahandountent to din&Hawing: l'
• r Division of Wider Resources,Underground hijc.ctiou Control Prdgram,
60.Water tercel below gnertuid surface:: . (it.) 1634 Mail Service ecritie,Raleigh,NC 27699-1636
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10c.For Water Stentilv&Tee icktion Wells: In addition to sendinglbefonn to
6e.-Outer casing lenpth(if known): (ft.) the achiress(es) above.: aEo subniit'one copy-of this form Within 39 days of
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• . completion.of Well abandonment co:the county health departntent of the,county
Where abandoned,
6E Inner casing/tubing length rif!mono): (ft.) ' .
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6g.Screen length(if!Mom!): . . _OE) .
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'Form pw-in Nonlitarolim Derrarimco cif Endrosuma0 and Naiural ficsou:res-Divisbaapf Water It.qauccs Revised Atigusi 201:1
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