Montgomery_Well Abandonment_20240301

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WELL ABANDONMENT RECORD For i I
This formcan be sedl for single ormultipla 1sells - _ I
1.Well('antraetor Information:
)tion: 4...., ....,"` WELL ABANDONMENT DETAILS
John Eisenman 7a.Nmnhcr of hells being ale Indoued: 1
Well Coatroom Name(or well owner t4_rso:Lally rtba:dotting nett on Insdier oration) For rmdr1ple lei;ecaoa a' r>IJu naree strly.h• w:elis ONLY w ub rim awn+'
R2r11+trucflyd,ithoodoorf,Jenr,pre cxtJt,!!110,UIJt r4k',1011.
4439A
71).Approximate volume of water remaining in well(s)9 (gal.)
Nc Well Comenaor Cot ilicaliOn Number
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
r
Company Name 7c.Type of disinfectant used:1,
2.Welt Construction Permit t#:. .
lase a/ igtpl,'cutle well r c!r•,rr/LL t.e Crwrihl St,iye.l iirianre.!Veclime,a:i•.i lF,AnowtJ 7d.Amount of diSinfl'l'tiLUI used:
3.Welt use(obeli(well use):
Water Supply Well: 7e.Sealing materials used(chccl:all that apply):
❑Agri a rural ❑Municip tlIP lbtic IN Nett Cement(root 0 Bentonite Chips or Pellets
❑Geothermal(Hcatdng1Coolin Supply) ❑Residential Water Supply(single) ❑Sal°Cement Grunt • 0 Dry Clay
❑lndltstrialfComnterrial ❑Residential Water Supply(shared) El Conc&ecc Grout 0 Drill Cuttings
❑Irrigation ❑Specialty Grout • ❑Gravel
Non-Water Supply'Welt: ❑Bentonite Slum ❑Other(explain under?g)
PIMunitoring ❑Recovery
injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GrounduaterReutediaiion Neat Cem.:94lb ,Wtr:7ga1. Sand Cem.:lb ,Wtr:gal.
❑Agtufer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Slomnvater Drainage
❑Experimental Te Imuologv ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
°Geothermal(Closed Loop) °Tracer
well was full of debris at surface, overdrill to bottom of
. OGeothermal(lietting+Cooling Return) °Otlter4explain under 7g1
borehole, then pump portland through tremie pipe from bottom
4.Datewell(s)ah;rndoned: 1-3-24 of hole to surface . p. —. • �.
Sa.Well location: t.- i—.i�V,L...L)
Mullinix Grocery 1VIHI' •) I ZuL4
tracilityiOn rear Name Facility ION of oolitic-able) 8•Certification:
_ _`}mortr-,a:;;;1 ?rn, y*4 Ufa
3079 NC Hwy 109 North, Troy, NC 27371 �s"`- _ - Dweeino /2024
Physical Address.Cite.and Zip ')iL,Ut�ti;5.•: 'ai,Ti.cat 1.41i4:C :+ -i:f1c' Mae
Montgomery 7600 00 07 7264 _ Br.vxattng this,'_,L, ....--- .-:iifr that the treks) was(uerei aharulonc'd at
Conch Parcel Identitientiatt No.{PIN) accordance with kid. ',dC 02C.11100 or 2C.0200 Wei/Construction Standards
and tfraf a copy of this record has been prnrided fo Ike well owner,
514 latitude and longitude in degrecafnlinutesfseconds or decimal degrees: j
of well("sad,arm laving is%ntiicxisl 9.Site diagram or additional well details:
You tray use the back of this page',td provide additional well site details or well
35.4145553 N -80.0040240 W abandonment details..You may also attach additional pages if necessary.
i'ONSTittlC7'ION DETAILS OF%YELL{S}BEING ABANDONED b URh11TTA}.INSTRUCTIONS
:iftcdr hell mwYtradiort recvrdlii!1,wwkvle. Phr miikiple in:maiorr or Liars-irol r snppir 1
iwi/,r ONLY writ fbx•:amt.ewe.r.•rxoon'arrurelfntlnenf_1,Jr1 evil sulortl/cureibenr. Ion. For All Wells: Submit this'fdmr within 30 days of completion of well
abandonment to the following: 1
6a.Well 11)#: -3
Division of"rater Resources.Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6h.Total well depth: 25 (fa.)
lob.For inicclion Wells: in addition to sending the form to the address itt IUa
fie.Borehole diameter:2 (in.) above.also submit one copy'of this'form within 30 days of completion of well
abandomttcru to the following:
Division of Water Resources,Underground Injection Control Program.
641.Water level below ground surface: (ft) • 1636 Mail Service Ceittei-,Raleigh,NC 27699-1636
lac.Fur Water Snook& luiCiato I ':'ells: in addition to&noting the form to
6e.Outer casing Icngth{if Iamown): (ft) the address(es) above. also submit`one copy of this form within 3t1 days of
completion of well abandonment to the calmly health department of the county
where abarudonctl, I '
6L Inner casing/tubing length of Munro): 10 (ft.)
64.Screen length(if known):15 (ft.)
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Font)OW-311 Noah Carolina Uepatlntt nt of Emiaom end ad Natural Resouu"Ce]-L}i+mica or Water itcsourue s noised Angua 201