Catawba_Well Abandonment_20240617 (3)

WELL ABANDONMENT RECORD For macrMl Use ONLY
This form ran be used for single or multiple wells
1.Well Costromr Informsdor: WELL ABANDONMENT DETAILS
John Eisenmoan 7a.Number of wills licitgt abandoned: 1
Well Cotaractor Nanr tot hell owrrr p;rAijWl%abasdoinug well on hn'Iier piopcttti i Flo• Nulnple aqv0wor ,w srm-"ewer awpph wefts ONLY Minh dw seller
ewnrrm,o'.Y1 irhamMwroe nr.Iris exw.vmhwn ow fines.
4439
NC Well Nnaticr
7h.Approximate snhtme of water remaining in wdlls)0 (XNL)
CoMrndorCetlibalir•n
SAEDACCO FOR WATERStiPPLl•WELISONIA:
Conlpun frank 7c.Ti pe of disinfectant used:na
2.Well Construction Perot 4:,
tut,dl,4*A-uAk wvft pnrmur o.e a ounq,.Vu*.I dnruece hoectiun,etc%i if kliowro
"d. �wunint n(di+infsYtenl uxd:
J.Well u.e(cheat well"se)—
Water Supple Well: 7e.Scaling;material..u.nl(check all that apply):
7 Agncuhural ❑Mmucipal/rulsix bd Nest Ccmcnt Grout ❑ Bclaonrtc Chips or Aclkts
0(kot6ennal(Hcanng C'ooting Supp1}i ❑Resicleratal Water Supply(mingle) ❑ Sand C'entent Grout ❑ Dry Cis%
❑IndusinaPCommercial ❑Residential Witter Supply(shared) ❑ Concrete Groul ❑ Drill Collings
❑Ira (run ❑ Spmlalt}Grout ❑ Gra%cl
Now-Water Supph 11 cii: 1-1 Hentomle Slum O Other(explain under 7g)
❑N10111tonne ®Roan en
Injection Well: 7f.For each material.elected chow.provide amount of materials tined:
❑Aquila Recharge ❑GrcundNaterRciedixion Neat Cem. :941b ,Wtr:7gal Sand Cem. :lb ,Wtr:gal.
❑Agmfer Storage and Reco%crt ❑Salinity Bamcr
❑Aquifer Pest ❑Stommater Drainage — -- ------- ---
❑Expenniental Teclmoio n ❑SIli1uMxc Colrtol 7R.Pro idly a brief description of the ahanek(nment procedure:
CJGeotheniml(Closed i.00pi ClTracer
lJGeothennal Me-inn ,Coolie ReMm) UOtherl explain under 7 ) run tremie pipe to bottom of well and pump portland until it
reaches surface -. . _
f.Date welhsl ahandnncdc 5-3-24 s� r
54.Wilt Mwation: 2024
GE ir(®IWA i.rii i'•crdwwn,o L*A
x.Crnilkathln:
I Pr. -,r ti,i I, I .!LIr IT)M
i
1223 Fairgrove Church Road SE Hickory, 28602 Ca � 5/12/2024
.sit._-.���•�.. .._ .. _. _...
PMsical Address.Cai.aid Zip a"AU•�+irtcr 130611
111•snXneriR Aix""_ _1 -s-.4_::+iJy IAW the well(s) was iivm)abmidoned in
C•omar Parcel Idearficalion No.4PI\i actonkrae•e with`1j.4,VC.4C 021C.0100 or X OXV(fell C omvirteclion StesneAin/.s
rmd that a copy n!this record tun•be-cis ri rwided to the well owner.
Sb.Latitude and lanRibrde in dc(trecs/minutes/secnnds or decimal ttcrytrccs:
ofucll field olle b0ong is snffe,ctai 9.Site diagram or additional Nell details:
You nun use the hack of this page to pi m ide atdditidnm:d well site details or well
N W' abandonnteni detaib. you ma% also attach mWittottal pages if nec:essan
('ONSTRU(TION DETAILS OF%TLLIS)BEING AB 0,I)ONFD SF BMiTTAI.INSTRUCTIONS
.Itiufh Nee rwa0ru0nm n•crir.h+,A muiUlk. 14v mulupl. .i i:rr.wlry+il
wrtd.t)Nl.l NiUI(IK.W/IKIu/f1f/HtrMNlLLnwrhimirnl.)oercnn uhmHarc�.nn 10a. For All Wdb• Submit flits; fdmn Nithm 10 dms of completion of well
i:e.11 cII I1/= unknown abandonment to the following
Di.isian of Water R"iurrm.Information Processing Unit,
lib, Intel Ndl depth: 60
1617 Mail Scnity Center,Raleigh.NC 2 7 699-161 7
(ft.)
101s.For Iniecdon W'dls: in addition to sending the form to[tie address in IOa
a o%c. also submit one copy of this form%whin 30 dins of completion of well
ire,Kin•ludc dipmcter: 4 (lo.) :rbattdonntew to the following
Di.iaon of Water Rvuurcez.Cndergniund Inim-don Control Pnsgraut.
6d.W art r k�el hrinN Ltvund wrfatr: 20 (ft.► 163e1 Mail Scnice(enter.Raid%h•NC 27699-1636
na Inc. For Water Suonh.& Iniccthm Well.: to addition to sending the fonts to
6e.(Futcrcasinmtlett>thliikanwnl: ID.) tlk address(esi abote. also subom one cop} of this form atthin 10 dtns of
comptctiau of hell abandonment to the counts health department of the court}
Im 6f.Inner casinLltuhioLk-nLKhlifknaNni: na Ifs.) here ahandoned
6X,Screen length(if knoN n is na (ft.)
Form GW-K) North Carolint fktunnva ofEmiromlxni;nd Natural Resources-Disiston of Water Rmwvcs Res red August yl I;