Rowan_Well Abandonment_20240318 (4)

WELL ABANDONMENT RECORD Faltta—IUseONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: SELL ABANDONMFN I DE I All S
Stefan Smith 7s.Number of wells bctuL abandoned: 1
Well Cotaracror Natne lot NC)I oMntr pcnnnalh alun&llnn�Nell kill his lien pl,tpem, For mu/opk altrli,aul ,w ww-wafer tkppil refs 0%1 1
a.xstfrncrkwt ah,«khw«rrrtr,w«iw.wAwit,weh,nn
3576A
7b.Approximte m a volue of water remainiox in welNs1�.13
NC Wc11 ComrkNa Ccnificantnu Npn#ur IEal.l
SAEDACCO FOR WATER SUPPLY WELIN ONLY:
Conpaa>Name lc.Type of disinfectaru osed:
2.Well Construction Peron M:,
L.i:di dlylra„hJr Me7l,vrmuLr u e i'*nn,.Sin*.tan nr Me-It-c el, .,rAno.,
74.Amrmnt of disinfiYtant uswtil:
J.µ'dI use(check well nse1:
Water Supply Well: 7e.Salialt nutetiAls u+cd lrheck all chat apply):
❑Agricultural ❑MunncipaL.Public ❑New Ccmcnt C;roul ® Dcaon tc Chips or Pellets
O(rntbertal(Hcanttg Cooling Supph) ❑Readcrotal Water Supple(single) ❑ Sand C'emeru Grout 0 Dn Clan
❑IrldtrstnaUCommercnal ❑Residential Water Supph Island) ❑Cam-wee Grout ❑ Doll Cuffrps
D lr •tk,n ❑ Specwlty Gem ❑Gra%el
Non-Water Supply R'ell: ❑Bettorule Slum IJ Other(explain under 7g)
EklonitonnL ❑Rccovrn
Injection Well: ?<For each material selected allay,provide A nwont„f materials soled:
❑Aquifer Recharbe ❑Crtou»duster Rentedtatnon
❑Aquifer Storage and Reco%en ❑Salmi Hamer
Bentonite.:651b ,Wtr:gal.
❑Aquifer"Pest ❑Stonmt:tcr Drarrutec —.
❑Experirrtnual Tcchnolog ❑Subsldence Control 7L,Print ide a brief description of the abandonment procedure:
OGeothenual(CTosed Loop) ❑Tracer
Ofieothemral 41-leating-lCooling,Rdurrnt r10ttkn icy lain toAef'):1 Pour
4 Date aclllaishamloncd: 3-6-2024
S&Well location:
BLtM Nails
>i.CeHifkaHeu:
Faciliny+owaer ,
111 E. Main St. Rockwell, NC 28138 3/11/2024
Phpoieal Addrem Gil).ad Zip C tote .C entfted Well C ontrxMt,r Well Ovbitrr DW
Rowan fit.'.signing then l a'nt. f hereby corn&thar the w'efl(s) was/werer abandoned in
r ool d, Passed WotilSation No.(PMI rrccnnhrtrr•e with l M.4C..4C 02C,O100 or X-(120)Well C onshuc'tion%witlords
and that a corn•of this reefed has been provided to the well owner.
Sh.Latitude and longitude in dcpreta/minuteNsmseds or decimd dqpwc
,,1„cG 1>1,1 olY I u k,qv,..nit,_ ,a; 9.Site diagram or Additional well 4MAds:
You nrn use the back of this page to pKA ide addrtrcnwl cell site details or cell
35.851137 N 80.406361 W abatndounteru details. You nun also attach addntontal pages if n ecessan
CONSTRUCTION DETAILS OF WEIJAS1 BEING ABANDONED SUBMMAL MSTRIiMONS
Attach well cvmrnr«crwtt rnevrdrs,t/,nr«lakW lv,r tmt/nple aWaimt a'twit-»veer r«pp(r
,tr11.v ONLY.,th the u«ar awe&w(kmt ab ankmosel r_too can snbnert,ser N,rnr 1[la. For UI We h: Suhnut them form witbro �cl dad-s of complaan of ur11
6a.Well IDat:Mw-g
ab:ndonmcnl to the folbuintg
Dhision of Water Re oarro,Information Prucerling I.nil
iob.Total well depth: 58.8 M.) 1617 Mail Service Center,Raleigh.M'2 1699-1 6 1 7
111b.For lalediwl Wells: [it atkluoxn to bending the form to the address oil Ilia
afxnc. also submit one copy of this form milito ;,>d:nti of completion of cell
ow.Morrledc diAorcler:2 lit.) abandonntea to the follouing
hd.Water kid helaw grrwn d surface 42 (h.) Division of Water Resiources,t ndct jr,gtnd Injection Control Program.
1636 Mail%mice('cnn'r.R:deirtt,M'27699-16M
Inc.For Water Suotrly& Inkctiuo In addition to sending the font to
6e.Outer casing length litlaowol: (k•) few addresslest abcne. also suboot air ;opt of this fora within Ill d:ns of
completion of rscll abandmmivnr to the couriv. health dcpartntett of the coum
u hcrc ahrndomd
6f.InnercasinrhnhinL Irn)th lif ksown):
6r,Screen Ivw4th(if know n l: 011.)
Fomt GW-3n Non Catuutn Dcpunntem of Eu%iromoc a and Narurai Resources-Dh csoo■of W ato R uurcas Rcti tscd Atsgusr?ttl t