Rowan_Well Abandonment_20240318 (5)

WELL ABANDONMENT RECORD For lo7emal Use ONLY
This form can be used for single or multiple wells I J
1.Well Cant air r InformatiM WELL ABANb(INMEET Runs
Stefan Smith la.Number ofwdlsbditabandened: 1
w'eil C(,Iraclut%.hilt.for NCIIoN oet push itrlh absisdoinng Nell on hislier properly) FW mi,lroplle hvft1M or iv,N-w arer ttrpph o,VLI rrrlt 14e Jratrir
oNafnr,rr n a7laanAwr7wAY ww oar.vvtw of,Nor fiem
3576A
lb.Approximate\tdume orwatrrrrinainin%inwell(NI?3 i�al.o
NC Well ConlractorCcniforalion Nwitxr
FOR W'ATFR St PPl l N%I I I.�0s,1 1:
SAEDACCO
Corps►Nanx ?c.1yIreof dianfectanl u,ed:
2.Well Construction Permlt C, c
list,dl,q.r,l::,thh w<•1!;r�,.nt,.,.r. ,wM.SAwr.lurtamce.Intrcixaw,Qr.,iJ kmnn
'd. 1mrKmt of Jisinfictant ux•J:
J.WdI use-Chet 1,bell u.r l:
W'atcr supply W(L11: 7e.Sraling ntatenak used tchtel,an that apply):
❑Agrwultural ❑hluniupaLPublic ❑ Neat(emem Grout ®Bcntonac Chips or Pellets
❑Ccothcrmal(Ncanne Cooling Srgo l ❑Rcsidcrroal W:aicr Snpph nsingl o ❑Sand C cnterit Grout ❑Dn Cta}
❑Irdusinal'(-ommcrcjai ❑Rcsidcrtial Water 1niWh i4sartd) 0 Ctm-mieGrow ❑DrillCultings
❑Im •tan ❑SM-min Grout ❑Gm el
Tian-Water Smpph Well- ❑Bentonite Slum 1_I Other lexplain under'gl
h9Mtnatonne ❑Reco%en
Injection Well: 7f.For each material w4ected alioir,11111%We AM 141 ft t art'matcrialsiwe4:
❑Aquter Recharge ❑Groundwater Rentedmficin
❑Aqutfer Storage and RecoNen ❑Salituh Bamcr
Bentonite. :671b ,Wtr:gal.
❑Agmfn 7'tst OSlommata Drainagr --
DEs3ienrrirnWl Tttihtwbgn OSifistdefre Control 7 tit.I'miide a brief dawription of tht ahandtininent prncrdurr:
❑Geothernial(Closed Limp) ❑Tracer
Pour
OGeothemial(fieann .'Coolin Return) 00ther 4explain under 7gt
4.Date wells)aMorinned: 3-6-2024
AS.%ell ha-ation:
BRM Nails
S.Certification:
Facility O..rcK Nml, Facility am(Wapplicabkl 7 _^
It1�G,'iidr:•.'i 1 . SCrir:-.�u3%11/2024
111 E. Main St. Rockwell, NC 28138 �tuw;mc
iQ-'_1�
PM sical.4dilacss.(ii..and Zip •.Cenified Well Cowracrnr or Well Owner Oak
Rowan lit.signing Mar Jbrm. 1 hereby cernfV thor the well(s)wear(were!Avid need or
Consul 1'XLcl lJ:tu,lb<JIX)u Nl, ,PINT ocrorrhowe with 1.1.4.v(AC 02C.0100 or X 0:00 Well Cronstrwhorf Vrntdtrnlr
rind that n onm of rhrs rewind Am•beer prrn=ided to the well owner.
Sb.latft*and longitude in degrretilininutewlseeonds or deeiniA degr'ev
tifwell fieid m.hit Mu.1.,nllicmv 9.Site diagram or additional well details•
You um\ nbe the back of this page to prcn de additional well site details or hell
35.851137 N 80.406361 W abatdonoient details. You mm also:Vlach addniotal pages if nmmsatt-
CONSTRUCTIONDE'rAll.sOFAFLI_(Si BEING ABANDONED SURMITTAI.INSTRUCTIONS
.tlfkfr»CR roacle,.. c,dnrle mtettwa,r wri-otwer�;,PJh.
",41YONLI'wadi(& . _................. l0a. For All %elk: Submit itin torn utrhtn ;0 dues of completion of\cell
6a.Wen lD#:mw-4 ahandonnicnn in the fnllmting
Diiision of Water Rtesoarm.Infin-niation Procesang Unit.
bb.Taal*ell depth: 59
1617 Mail Seniee(enter,Ralrigh.M'27699-16L7
(n•)
lob. For Injection Wdis: In aMition to xidme floc torn to the address in Isla
6e,Boreliide diawrctrr.2 (lt.l abme- a6o subutu ons:copy of flan form widim 'so day s of completion of well
ahardonmcin to the followma
Di%Won-if mer Rrsuurees,Under=1vuud Injmdon Control Program,
6d.Water kcdho hew griotnd.wrface: 41 (h.l
ltiJt.Mail Srnice Cater,Naleigb,lrC 276994636
6c.0utrrcasing length 1if laowal: (h l Inc. For Water Suuule A Iuieyiiow%'eNs: In addition to steWirut live form to
the addmslesj atwee. also submit ooe cop} of this form within 11, dhs of
completion of well abandonment to the court-, health deparmicru of the corirm
where abandoncd
W.Inner casingrhibing lcn:,ah cif I.nms is is (R.1
6=.&leea length(if W1411%nis
North Carolirn Ikpanurrw of En.tronnien:end Nattital Resoaaees-Dis tsion of Water Roioutces Re%"Aupisi A)1 i