Catawba_Well Abandonment_20240617 (4)

WELL ABANDONMENT RECORD Ac6 For ltM MO Use ONLY
s.
This shrug can be used for singk or multiple wells
1.Well Contractor Information: \� WELL ABANDONMENT DETAILS
John Eisenman 7a.Number of wells beinpt abandoned: 1
wail t'�•(ennui Manic for*di riCr personalb abandoning ac•il oo tin i r propcn)t For Mnlo�fe infection or non-sorer ;twitch wells ONLY wdtb Me Mt' .
ttWLYIrwa CIO/1 14,,1100/I14i5,U,'OM t tlSI IWt/t war k,rsu
4439
7b.Approximate scalars of water remaining in w+c0i.19 Igal.l
NC Well Contractor Certification NIt ntlt:T
FOR WATER SUPPLY WELISONLY:
SAEDACCO
Conpitrr>Name 7c.'fy pe of disunfectam uaed:na
2.Well Construction Permit M:i ,
Liu.11 s liable well ttrnriir u.s.Crm A'..)'rate.Variance.liyecturn,eft)ifbni n d. amount of disinfectant used:
3.Well use(cheek well use):
Water Supply Wc91: Te.Scaling materials used icheck all that apply):
❑Agncultural ❑Municipal'Public 6t Nutt Cement Grout ❑ Bentonnc Chips or Pellets
❑Geothermal tHcanng"C'ooling Supply) ❑Residetrtral Water Supph (single) ❑ Sand Cenretu Grout ❑ Dn Clay
❑IndustrulCommercial ❑Rcsidertial Water Supph(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gras el
Non-Water Supph Will: ❑ Bentonite Slum LI Other(explain under'gl
❑Monuonne ®Recovers
Injection w ell: 7f.For each material selected whose,pros ide amount of materials used:
tlAquiferRecharge ❑GroundwaterRemedimron Neat Cem. :941b ,Wtr:7gal. Sand Cem. :lb ,Wtr:gal.
❑Aquifer Storage and Recover ❑Salituty flamer
❑Aquifer Pest ❑Stomwsatcr Drainage --
❑E pentitenal l echnoloey ❑Subsidence Control 7R.hosing a brief description of the abandonment procedure:
'Geothermal(Closed hoop) ❑Tracer
run tremie pipe to bottom of well and pump Portland into
1Geothental 1Neiting"Cooling Returns IlOthctIexplain under 7g)
well to displace water until portland reaches surface
1. Date tiellt.l abandoned: 5-3-24
5a. .1c1►location: L. +! La
GE : 1 '1 A24
N.Certification:IDa of applkablo
�r6if7tt•rl�rG�Mw3f1024
1223 Fairgrove Church Road SE Hickory, 28602
Physical Address.Cut.and Zip Sipratr K=a > ur l-•-a:';,:• ales Due
Catawba By signing dux that the wilts) was(were)abandoned in C'oenr� t'.n:cl IJ,a,t mil N. ;I•t', acconlaiwe tiCAC 02C.Itlrn)or X'.0200 Well Construction Standards
and that a ceyn'of this record has he,en provided to the well owner.
ch.1;trimdr and longitude in dcgrcesiminutcslsrrnnds or decimal degrees:
I,.I uric Lis k,ng r.,u1licRiti i 9.Site diagram or additional well details:
You nun tine the back of this page to pros ide additional well site details or well
N W abandonment details. You nay also attach additional paws if necessary( ()\a'IRUCTION DETAILS OF WELLiS)BEING ABANDONED SUBMITTAI.INSTRUCTIONS
Hall tn2slrudn,rr rnrwdu.,:at whl,k. Jr.,mum ph-estee Iiov ru re,n•a.a;c,
,t.i t ONLY with the tune•urn+haiebosr W,wnk•wveot_Iw eta!trrhm,t Oire•.k,rm Ina. For All Wells: Submit this fort within ;0 days of completion of well
6a.Well[DO:
BR-03 alruxlonnicm in the following
Disisian of Water Resurces.Information Processing limit.
1617 Mail Seri ice('enter.Raleigh.N('27699-1617
6h,Total well depth: 100 (n,)
lMb.for Inlenion W.b: In addition to sending die soma to the address in Ioa
ire.Borehole diameter: 6 (pit-) above. also submit one copy of tins tome within 30 days of completion of well
abandonment to the following
Division of Water Resources,Underground Injection Control Program.
het.5 stet letrl belnn around wriace: 20 (ft.) 1636 Mail Seri ice('enter.Raleigh.NC 27699-1636
Inc. For Water Snouts & Infection WeIl*: in addition to sending the form to
tic.Outer casing knells lir!moss ni: na ft.) the addresstesl abose. also submit one cope of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned
6f.Inner casing'tobine length,it Litrrn n,: na ,ft.)
61.Screen length of know n t:na Pt.)
Font'GW-.km Non h Carol tin Department of Ens nomad and Naomi Resotaces-Dis isioa of Warr Resources Res and August:(r I t