Catawba_Well Abandonment_20240617

WELL ABANDONMENT RECORD For ltrleritel Use ONLY
This font can be used for single or multiple wells
1.Wen Contractor Inforintltiria: WELL ABANDONMENT DETAIla4
John Eiseriman 7a.Number of welts heitgl abandoned: 1
w'01(•untraom Nana tof till holm plupat5) For erdnpk rnlecrwn or .,-a-.Wtfer srpplY well• 0%1 1 NL
o assisw unit lhrin(*MMWW.WiN tWr,111oif(we Jnf1A.
4439
NC Well Coraracror Cerltfilaur n Non 11cr 7b.Approximate snlome of water remaining in w rll(s 1sP i gat.)
SAEDACCO FOR WATER SUPPLY WELI 5ON1 1:
Compum Namc 7c.T%pe of disinfectant used:na
2.Well Construction Petsit M ,
lltr Idl thvplH oble u<•b jwrmrl.r,i.e.('IMINt,Ssi i .I'drNais hosedinlr,e'h•.t Ithsiown
7d.Amount of disinfectant u%el:
3-Well use(check well uar):
Water Supply Well; 7C.Scaling materials used(check all that apply):
❑Agricultural ❑MtunicipalrPublic k Ncai Cemcm Gran ❑ Bcntonitc Chips or Pellets
❑Cieotherinsl 4Heanng,'C•oohng Supph► ❑Rcsidenruol Water Supply-(singles ❑ Sand Ccorcm Grout ❑ Din Clay
❑IrdustrialsCommcrcial ❑Residetatal Water Supply,Isle _ + ❑Concrete Grout ❑ Drill Cuttings
hnPhotl ❑ Spmiah�Grout ❑ Gratel
f an-%%ater Supply%fell.- U Bentonne Slum ILI Other(explain under 7g)
JMonntonne GRecocen
Injection Well: X For each material selected abort,proside amount of materials used:
❑Aquder Recharge ❑Groundwater Reniediation Neat Cem. :941b ,Wtr:7gal. Sand Cem. :lb ,Wtr:gal.
❑Agmfer Storage and Recoser% ❑Sahmh Barer
El Aquifer Pest ❑Stornsater Drainage
❑Experimental I cthnoloe. ❑Sttlsndetre Control 7^-Prnrirk a brief descrtpunn of the ahaorltmmcnt procedure:
I.IGeothennal(Closed Loops uTracer
run tremie pipe to bottom of well and pump portland until it
IJGeottienttal(Nc:tnnl.:�C'ixolin Return ++(lttmcr(cr tin utder 7 )
reaches surface
J. Date wclUslahand„ntl.rl: 5-3-24 ", r
c�
zit.N1cll list atton: JUN 17 2024
GE
I vlctNam FacilisIA,;;:-:;t,pl.-lhlcl R•Crrtilkatirwr: If�lx•J -Ci1 •GC41N:�.�U"
1223 Fairgrone Church Road SE Hickory, 28602 "� - 5/12/2024
Pin sical Address.Cnh.and Zip 5gpal :<:.:i�F,•W.,i;0.w -,:a--k•r.itr- Dale
�eJt�aR/ C tS�C�r�a.�9
Bly slgrur{g duo ::::? _:Vtt that the well(s) was(were)ahanlAmed in
Uouuh 1"1'0 Idelu110.-:rolm No.(PIN( act'orrlrtnc•e wix I Ui SUAC 01C,0100 or X-.0200 Well Canxtruchoa.M mrkirds
and that a rnpr of thts record has•hirer provided to the well owner.
th.Latitude and longitude in dcvvvAlminute%Acvrods or decimal degrees:
If 14c11 Wd olx Uu k,q 11.,Id11001 F 9.Site diagram or additional well iktails•
You nun the the back of this page to prm de addiliomil well site details or well
N 11 Aatdonntenl detail You nos also aitach additional pages if necessan
CONSTRUCTION DETAILS OFWCLUS)BEIs(. IN%\D0\1.P SUBMITTALtNSTl[ICTIONS
.Hrrd,ov/1...m1rLdflll!rt•ITIM111)!I➢.WlIffl*. ;41r n.r r. w1Th'
arfix ONLY IIith Aw.mmwu mfm(wit Ma. For All Wells• Suhnut this form wnhm ;U dad.; of completion a well
6a.Wttl IDa:BR-01
than donnlcnn to the following
Disisiou of Water Rewrurcm,Information Prvcn ang t nit.
Ms.Tittal well depth: 103
1617 Nimil Senice Center,Raleigh.NC 27W)-1617
(fM.l
11Ib. For Inleclistile Wells: In addition to sending the form to the ddiess in IOa
n.c.Ronlwde diamek•r: 6 Uri.) abote. also submit one coP% of[his form within III days of completion of well
abardonmetu to the following
Disision of Water Rexrwrces,Underkrattad Injection ConInil Program.
6t1.Water keel below ground wrfan: 20 ift.) 1636 Mail Service Center.Raleigh,N('27699-1630
6r.Ouhr casing Irnrth tiC Imow nt: nit
Ilk. For Nater Suouh & Injection Wells: lot addition to sends the fort to
(ft)
t11e address(es1 above. also submit once cop} of this form within in days of
completion of well abandonment to the count% health dcpanmema of the-otitat
6f.toner casing,+tubing lengthlength tit'I.nownl: nit ift) whcrc ahindoncd
6l.Scrccn len{Mh(if know in I:na ifl.l
Foils (;u- 1, NonYCaroluu I tifclnnrra ofEmirotuncm and Naiwrat Rcsottrces-Disisionof Waicr R.soluces FU%md AuguA 1411 t