Rowan_Well Abandonment_20240318 (3)

WELL ABANDONMENT RECORD Few lnermlUscONIN
This form can be used for single or multiple wells
1.Wed Contractor Infurmarioa WELL ABANDONMENT DETAIf ti
Stefan Smith 7a.Number of,*dls being abandoned:
l
Well Cotorallm Naafi Itll%ell MILLY pYsotulti altiadomag sell on lttsarl pfolxn}r F,w mxlnplr ntlr.nrur ,w x rl-.ua•r sxptJi ft\f t
„dr�nrr,t+�N�,d,o•wRvrm,nr.r.,n,•w.rat�N:r,.aeM1,�ni
3576A
?h.Appriivimate iolumr of wattY rrnnainmr,in wcll(s1,3 LgaLl
NC Well Coairactorfeniftcatinn Nani\cr
FOR W ATER SIIPPI.Y WELLSONI.Y:
SAEDACCO
Conow"I Narlic ?c.1 I pr of disinfertam used:
2.Wdl Construction Permit M:,
la.,,•,, ,;:;,,-1r,r, ,,,•s,. „•,, —n,S1,,*e.I,-awe t,rrt.rrr,c rh. d im,rx ,d. %mount of diwafectant used:
3.W'dl use(check.w ell nse):
Water Supply Will: 7e,Sealing materials used(check all That apply):
❑Aprk:uhural ❑MumCgul,PuhhC (3 Neat Ceruetu Corot W Beraonite Chips or Pellets
❑Crnnccmtal(Ncaring"C ivAinr Supply I ❑Rcstdcri nal Water Sttpph Isinck) IJ Sand Centro(trout ❑ Dn Clay
❑Industnil Commercial ❑Rcstdcrital W:ucr Stipph'(shared) ❑Concrete Grail ❑ Drell Cuttings
❑1m •two ❑Spec-jkt %Grow ❑Grand
Non-Water ltMil%«ell: ❑Beaoaite Slurry ❑Other(explain under 7g)
Ehlutulonn:: ❑knoven
Inje ktion%rtl: ?<Ror oath aa(etial aeleeteed abevr,prnviie amount of nvaterials uteri:
❑Agmfer Recharge Mroutdwater Reniedtanton
❑Agwfa Storage and Recov'en ❑Salittih Barrier
❑AgmferTest OSlonnuaterDrinage Bentonite.:631b ,Ntr:gal.
❑Experimnual Techoolokn Osttbsl(kme('otirol
7*ltrtitt/e a brief description of the allanilllnnnrat prvicttilurr:
OGeolber(ital(Closed Loop) ❑Tracer
Pour
OGeotbemul ftallngiCooling Return) 0001CI(es lain udder 7_0 —
I.Date wellm abandoned: 3-6-2 0 2 4
5a.Well location:
BRM Nails
rxilo,(h\rcr Nawty Fxilih IDw(if aMlicabkl S.Cetlkfkatise: U1l� ;3,
111 E. Main St. Rockwell, NC 28138tz; 3/11/2024
Ph,sicaI A�ss.Cud.old Zip Certtfred Well Convacior of Well fM cr Dare
Rowan BI .sign(}(then J6rnt, I hereby cemjy thin the well(s) was iwen-, ahtvt,hpoed in
Coati\ Parcel ldeaulkaLlon No.(PIN( act'onhnrk'e with 1.1.4,VCAC OTC•0 00 or:(' O.VO Well Con.0varun Standunls
and little a ctnp,of this rerohd Ala bem prm-idled to ere well owner.
5b.Latitude and longitude in elegrccslminuteslseennds or decimal degrees:
pfw•ell fwld ore•Lu kmg I,.illlicirr) 9.Site diagram or additional well detaik:
You nun tbc elk bail,of this page lu pros kle anitlaional well site details or hell
35.851137 N 80.406361 W' abaudo n ken t details. You Idol also attach xWttwrtal pages if ivices-%an
(70NSTRUILMON DETAILS OF W'ELL(SI BEING ABANDONED SUBMMAL INSTRUCTIONS
.!loch Nrl!IYIR\frilL'INM!n--rd v if,nrnl.ahk•. hLr nrLfhp7r rnjre ht,x,.w rtun-Nvkr wjgth
N't'II.\'().�f-t NJf!rfk.NN1KtIM.\IrwL(NNrJr MAnrmmt.tuxcux ahmu+�tr.N.nr Ilia- For All Wdh Submit this fomt within 30 days of Completion of wYll
abandonment to the following
Dhishm of Water Rcuarcr%.Information Pruceveng Unit,
6b,Tocal mull dr t
1at: 58.8 1617 Mal Senior Center,Raleigh.NC 2?699-1617
fn.►
10b.For Imicethela We a: 1n atklidou lu xtdmt:the futut to Ilk atkltess Inn lua
above.a6o submit one eqA of din tour milit i to dins ol'cumpletton of well
(w.Ikrrrlwrle dianic(er:2 (in.) abandonntent to the"lowing
red.U;otrr kvel below grttwlld Wrfacv: 42 (ft.) Division of%later Resources,Undid r,Nrnd Inlccuun(mm,d Pi roll.
1636 Mail Senice Ccutcr. NC 276 4636
lit.For Walter Swunnnh & Initeti rem Ad1j: In addition to sending the form to
nr.Outer casinglcuohIiflawenl: (ft.) file addfess(est abuse. also subnw „tic copy of this form witlim III has of
completion of iiell atiandmutxnt to the.owns hatdb depannneni of[be:oum
w lure.thandowd
U.Inner casim.,4sbing kngth lif know n):_(ft.)
61; Scm-n length(if knowu): tYt.l
Femt GW-3(t No tt t:u Irm Depon,tin of En\rronnien old Natraal Resources Dis issos of Water ResLwa,s ke,"August P)I I