Avery_Well Abandonment_20240419

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'V LL:ABA DiO Nt&IENT RECORD... Fotxiit 1 ti :olgti...::
'' 'Phis fornnCan be used.foc,s1e orinuinpte:isrells..: '• ,
1.Welt Cnntr istor infartttatuoa � yItii°I AlIANIMNMENTDET#ILC
Brian Ewing 7a Yumberuttvdl+hcbt ab.rndoned 50
Weft oiicadiu'isacno(or�3 tt4r� p natl�lli�ndonina c 3lQnti alt‘rpr tf}:-• k�i` mu 0; i 4'0i.ror' 0: rt tiii.w saljp :'0( ONL} wtdh .;4ie ..Eiiii
e»4v+ittrettkit`trhfuntarn,cwt Sri amt Qitirit t�rrajiiiir
4240-8 • 7b Apppraxlmate vvrlawe of w.rter renuirnng in vieti(a) (fit.)•
NC�Ye]ICt�:sirattt+rC�Eii�tcatic#u2ltm�ict:
SAEDACCO E. '
FOR 1VA'l'�1tSUP1'I;Ti'1�'Bi :Oh`LY•:
Cart rain Dune: 7a'r` •ettt d1 Minfectdnt:uzetl.1
2 Well Cunstrucfion•Permit d c.
Lsi dltrp 1...tr b1c remit prxmt t!iz Co::,hV Strf 3'tirt xcr.h r io rl4,t�'R,nx r - .
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. ,, ,• • 7d,Amount•of dis.11ectant uswt..
3 WHHt use(chcd..tivdl use) • _
Water.Suppl Wck • 7c.Scaling nnaterials used(cbed all that apply)
• JAencuttnrat::. 1::4mrcipal/Pitbti , rPUlets CI Nit%Gcntent tst>attt D�crtntute cd►�o:
00roitven19.tt4icattt.6/094t*:•s pp1) Eltcsnd ntutI W'iter'$uppt�(single);' t 1 Saud Centcnt Grout. , ' •..n Ik CE
l7 tndtist iftl/Comntcrcial I7l4Acntiatl Winter Suppis sh.trcdl: Q Couercte GTOut :.O Dull cutt,n
• : Dlitiy,:ttto6,.;, ',. . , .'• .••. ' . • - •.• .•. : . ..; 9 Spcia ltr Gtuut:. I o Grasrel..
Non--Water Siippty Wc11; • . - .. 0.1)dut9xuto Shirt) :: ::0 Ot er;(e plknitt under 7g>;
t►tMonitonne • •. 4R :cii: i • , i• .
• Injection W.cji: •., ••-•. .:. . 7f Poi�caNt ntatcttal sctcrtrd ubo�r*pnumidc aniohut•of ntzifenals titcil
❑Agtuferl ti -••17Gr0wulr,Rcrltemcdhdiiau: • .
❑Aguifcr Stop a and It .oi CiY OSalrniic Barrier j :
Bentonite .501b ,Wtr gal
❑Aquifer Zest C IS{.in►�'".44:0 imago,..
DE+tp*14ivat Te baokgy . ASrrbstdet Coutini' 7, Pri►tide a trr`.ef•dc%cri tlou lof tht.3bundnument p rolldur.i
170eo41:nn4(Closed4op) i:JTmcer,
BENTONITE HYDRAULICLYIPUSHED:AND. PATCHED•.OVER
�lQeothettrtti til it igitoolutg Return) • ildijier'(eapiaiWa der 7g).� '.. .
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4 Datotircit(s)ahandoned, 3-7-29
1 :APR. 1. 9•Z014
$a. ctl.loe it n.; • • - .
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. itt4eiriit�k.•-ri P.r kt- s Ding.thi . .
i cility1.4tAi rNaLm : F0i14 Wgt•11, ,pl blie S Ccrtiticatirnt i�"�.G130G
•6741••N US.Hwy-19 E .Elk •Park, 28622 • - • Briar Euvlfl 3/10/2024
PI s,e tl AdthcSs.f5t1,and Grp • 4c�iAlji i-Mit:Er'u:d Well C,ii#4, .,r'It Oicit:r- - it*e
Avery fir.JJna(ng th,s Jonn 1 heteeby c r.'kf dial the i ell(e)w as ere)trhnxidaited nn
t.46.i :• . - 1 ant tdentifknUon No(Pita) r alai, trrdy 1 fiA.AVC;3G 42C•!tIQ/)or?C OOOD T(.elf Cans lint on•Srandknifr
`• vnall(rn{xt'cap)Fo,�7lir,�recardlrasb¢cnpmirlect(ollxriAclltns'ier
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$b Laittude and.bggitt do In de revs/minute lcecoadsor dears ii degrees.
ti•tw,0.fn�tQ 00:100ingissi,10400:: ,
"•:::: 9 Sits,dtgram:oraddlt1bualwe l'details .
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a is vse a f tl►is to add tstlal ltti S. . It n tl b e1.o. pate, pm de tit ll _ite details ig O..
tt W 03iiikifiiiiiikifiyaii*4io;*diSiiiiiiO4*i*iffit attik; :
•CONktittie 1'tthht DF`CAtt S t7F•WEI:USI BPINC ABANDONED CIl$AtITTAi.iNcTRucTro(s.
tftadr n'i 00.0/Ya 0.4i..t-r c*ia It avr dohte I Ur multi to r t Jnu!-rxr„njr&r ri d
uel4'.4:�'1)S,Milu s7tie or.�t,r ndu;.�7,a„. �tt,i ucou-# mttiuuH ii ` iod.;iror AIt 0.11 Submit ttii farm. s Ihin 3tt d r s of'completion of�c ll -
ei.', elt IDS`IP 1-50.
abandonment Id'tlic follottn> . '
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• Dit` ltrn 0V.4i r Cte.:out,<+ I0f.0.0 iikin P0,0•0 ng Emit,;:
• p .12...... 161711td,t its.Center 17ale th4 It.0 21699.1617::
6h` T6tatl�dt le tt .. (rr:.:;
1Ob Fpr ilnlectlsri Weds{ int addition to sending tbefonn to ithe addr s in'IOu::.
6c..Boreboie dIameter'2:25;
.thole=also submit one ,. tr alibis farm.within 3& days of coutpte tdni of gill.-
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. :.... ubatuiottrnent tit ttr fallonvin
))fn'isiontof WaterRecau�rc� Underground I,s ectfonGpntrnl Program
4d W.rtcrl0d:belowground•atrface - • {(t;) ,:-.14,*lt:rtl•Scnir ••CcntOr;1a10gb.;. ..C27679-1636 . - •
Ge.Oster cas,iip fcugtir tit lmntCn).:' {`. IOc Fo WatSr c1ronit&Injection Fella: itt addition to'sending the fonts tt.
the address(es);isbol'e also s'ubiinit one tops of.tilts form rvntinn 3t1=ttat's of
. cornplcuou of sell abanclomnent io ific colons;fi lth depattnienl of the count},
6f Inn:!.0.0 i iwtebins iot�tG t f ImGrvio; • .<(ft)
nbeicatnudoned .
• 6it Sores lent tb•(if lmti n) . (It)
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Fomk.i*,`]tl.4 Noit,tacuti**piitmmoi.pi ionmecttmid2laruraRcsaiiec-AihfsroriufWnicr csoancs>. -R tetsed•1wp�u 0t3;;