Mecklenburg_Well Abandonment_20230828 (11)

LL ABANDONMENT RECORD f
Far:ttnem,l l?s>;ONLY:. I '
- 'Ibis foot ran be used 4or single,or multiple rsclls-
i.WcEt.C4tlh:�ctor:InFnrurtttion: 1 ra\t� J WFLG ABAND(11 AWNT DETAILS,
Stefan Smith �\ 7a1.Almnherofwellsb►cifig abandoned: 2
1Yc11".Cnatr�ctorTam�(ar�ablioxeupu5gii�11}:di7u[dlilno':ieElanitislLerw-pcnyl ra irnrJtiple, rnlertiar W; rx�mrarer 3Jfgp) msF1� ONLY wltJJ N,V .sane.
. C�IN1YtRfCa(�Jlad�t�Lrt�fUtrJll.7lr,';lrlMave 5whjIJf OVlt3 rrWL .
3576A I •'•,
7b.Appmsimttte vnWuise of sat rein umnl;in ii�Il(a)?2 ' {;, ,j
NE tiVc11 Cgnl>octarCcn IGailiDa Nim bef
SAEDACCO FOR RYA TER S7PI lY IYEGLS ONLY."
Cdna any.awo 7e,Type.f)frlisinficfaut•uscd:.N/A
1 We11 Cansttuction Pemlt#:50000277,
LLttiJllnijllttv6leuriltnrmiir r.CmA.,State,
tarriirEalJaerlrorlrrcj.fffiiulwfJ Td,Amount ufd3alnfettsuit used:
-
3.�V�l u'sr"(ch"ecL�Yell,uae}: - -
Watcr.Supply.Weil: 7c.Scaling:�i►atcri:rls tt 1-(elrcct,all ihat apply):
l7Agticuthtal pllqunicip:rllP4rbifc" C1 t+Tcat Ccniciit.Grpttt- ti 13craomtc'Cl is or Pcliets
faCscodicrtntt(Hcatit►glt"oolino Snpply} l7ftcsicteritial tiYatcr Sul_ply(singlo) 17 Sl:. Certieui Grow tj'DtyClay
OluctitsttiallComrncrcial t7R�sidentinClV,trer Supply'{sh;tn d) �.�cinciete Grout O DriILCitltities
❑Uii lion 3'$pecinity.Grout. :I7:Gravel
I�tFII�Yatcr Sut►pip Wglh, _ CI-Hetaottite 51uny 17 Othei(espla;ttuader 7g),
O141utiitoriiie ORecoven-
•iujcetion Welh. X.For each material selected above,provide atuount-at materials used:
❑Aquifer`.ltecfialgd OGtoundiiater RemWWion
pAtiW46,.Stotilge ai rt ko Ltverq ❑S:tl Iy Bam,cr
❑Aiptifer Test OSto ��ater Druitwge:.
133entonite.:601b ,Wtr:5ga1.
t7E.Vetetit itl>(I 7`erlitrcilogG_ OStiUslrlevtti Ct►irtml 7 Providc'a brief description of the,ybandaoment hro&dur
06cot1wrmal(Chised,Loop) bTracer
Meoftnwl(HeattLy'Coolltl Return) 00dwr(E lainuader.7A)
Pour coated pellets.
.`� F=rP!R--
L j
d::Qatchclt(s).abandoned. 7/31./23 AUG 18 2023
Sa.Nvell location: Informa4iCn R c:zj!r�Unk
White Water Center 'D4'v`w'30G
F'¢ciliijlrhvii:r"Niurc Pa:ilitylDtt(ifaptilicablc) � $•Certilienlioit•
4779 Charlie Hipp Rd. Charlotte.; NC 28214
_
_ . 8/10/2023
PfitsicaFAddre$,Citp:aul.Zp we-- nc Mecklenburg Jjy.:signing lkts farilr,"I bettilly cerh,fyWart>lae a dift)was t arej abandoned in
Cauut? f atcel Identitirlt OJL:lo:(PIN)' 7JciutYlcntcc with"1:11 C2C 620-,Q100 tit 2G.03Q0 filch uiis7ialttlart 31riniktr[js
mriltlrcr/crcvpj�ofYltisrccnrcJkasbeelr.provir;'erLto'llre-ur11ou•rler..-
Sb:li ti(ade and lnn itudc In ttc ccsfminutes/scsririds or dcciU4.0 d.c'grces:.
(ir.yett rvtd,uta::601)iig"isxllrij;*II ) '9.Site d"an)or additional will details:
35.263786 81..005646 You may ilie 1lk.bkh-:ofihis page ta,pravidz;addi6eit�f tisxfl"sitg.derails"ort►ell.
N ;rbaudonntziudetails You tnay also vtach3ifiliGoital'pagcsitttecessaq_ '
. i
C'0NS'I7RlICT10Y DETAILS 6F WELLS)DONGARAN6ONED STUBMI-1717AT.-M,TRUCT10NS
:llfuth oirl!raeaslrircJirrn t card fite. ,nr,M"kjj1d iiije;iiuil rirmin•irdJ rx1wj+
urllsONLYfrIih/IJyatinleaorcttltrtir<ntrt4rrinfvmlrnt j.m,nnsirFami:tdir�Punic 10;G Fnr All �VelLc: Subnut'fts faint xiitliin 30 days of"complction of-nc11
atianAonmcnt to'tha'fo110'',n
6a,%Veil 1DgaS-38 g; I
i
Bivisinu of Water Rcnur>ciJnrqrxnqti4n Pra-ewainu Unit,
65 ) 1G17 t►Liil S&ieC Cmt6-,`R4 irti,NC 27699-1G17
6WTatal tsell depth:
ab.F r Inleellon Wells: In additiori.to sending.tile form to rile address to 10a
tic.Borehole diameter:2 . {�u y. above;aCso submit one copy of this forty within 3b°days of courpletion of-:veil
abaridonrileu!ld[ti1 lallallitty;
6d Water.tcvel.hetriwgrouridsltrfacc' 35. ((t;) Di�isiott:afVVmterRcsuurre�,Htder�ruunrlluj�et[ouCoiitrilProgrncu,
1636111:ri1 Sciiicc Center;Raleigh,i!C 276994 636
tic.Outcrc+3iog lcu h"(iflmonu); 60 {fP:) 10c,6or-%jjp.Sunjj1y. c Inieciran 1Vc11s: In addition to sending theform to
the:addrzss(esj above:also submit one!copy of this form tvilhin-30 days of
completion of%V ll abandotutmni to the aaruuy beatth departnieid of the con*
Gf.Inner uiyitit Jtubio turgtb(if latatitu):NA (ft.
�ifirrc abafWoticd.
6g.SuiIm length(if luiorry):5 (ft.)
Fenn G%1-30 NonliCatollm Dcpartmctil oTEatiroaineel aocl NluurslRcsflurccs—DIti•ls[ano[>•Jatultc.ouln.s 'Revised August 1013
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i
"WELL ABANDONMENT RECORD Fot IrAcrnal l3aaeoNLY:.
This foil can lie used lbr iingl;:or tuulliPle, lls
1.Wcl1 Contractor information: WELL ABANI)ONIHFNT DETAIL
R
Stefan Smith 72,Number of wells being abandoned:I 21
1l@It'CocYracfbrKamc(ortir LonecrprSarially;ulitnlla�i[noactlanldsllurpruperty) For nr0hple taycrltar ivr m;aa-muter! sirppa , wells ONLY with Mw srme
' [drl4firBtk�A'(dSralYlRrraaaC7ai,Iran CR?Sab)llt Oil form,
3576A
7b.Apprnsimatc i;nlnme of vFAhT nem':unmg in�iell(r)�2 j;aL)
NC�Vd1 CordractorCSgift�iliou Niroabcr -
SAEDACCo i OR.WA'Ti RSUP['I,VWEi tSONf ONLY.,
Con>pam hams 7e.Tvpe_tiftiWnfititant tkied:.N/A
2:•WclfConstruction Permit#:50000277
.Uis idl rrpnllcuble i'elllrrmat.F r%g.1 aattgn Age,1'urau xe.hrri-ffam,etc)iAwwxa 7d:Amount of tlLsinfectaait ust tl:
3.Well u-se(a hec):h'eU used:
Walter Suppty.Well: Vic.Seailing:indtcri:tis'tised(chccli all that apoly):
gAaricaituritt gltilunicipaUPUblic CI Ncai Oeutcrif.G(ortt. [R Rcntoiiitc:Chiiis or Pellets
Pellets
Suppl}'} 0Residen1Ld%VntcrSo PP
l}•(single) 13 SaM.0 nett Gr6nt q'Diy'CLry
CliildisswallCommett:ial MesidentialNVatcrSnppl,(struod) ConcretdGrout ODrilLCitllings
❑im lion D Speciult}Grout d]:Grate]
Nnn lY to Sirppty Wcll: b bentouite Shiny 0 Other(csp)ain-under 7g1
OMailllUrillL' MRecotiew
injection Well: 7f For each material selected abofc,pooiide amount•af,materials used:
❑Aq"niferttcebar+oe (lOGrgtdidi}atec-Rerucdiotion- .
t7e (tiifei Storage an i,Recoven, gSalinify Ranier
OAiinifii Test USlonri}satcrD'riln tge
Bentonite.:351b ,Wtr:2gal. :
OExperimanal TwImplogv: OSuUs)ctetb-e Cointtil T; Provide a brief it eriptian of the tihaudnnmcnt Anti urr:
l9Geolhermal(Closed Loop) OT Ocer
Pour coated pellets. And hydrated.
OGeothermal(IicntingCooHimReturn) PlOdwr(. Iainunderlrq
I -
���� �� `m i pp �..
d D.'atcvsctl(s).abandrincd. 7/31/23, 4! V p�L)
Sa.Well locat(on: AUG 2:8 2023
White Water Center
rac8ft?lowi;crNamc rxiiit?>Dm 6rappitcatiic) $.Cct�ifteatiou: lri€izr�ratiCtt t'rer.�tsot'�tltttf
4779 Charlie Hipp Rd. Charlotte, NC' 28219 _bj� _ i 8/10/2023
Phvskal'Addms,City;and Zip S. "InrC•:.;CCtliti�t 1Vrs1 o1ar.Ktnr er 1Ve11()i�ta r pate
Mecklenburg d3}r:si3rrafng Plats/arita, f'Jier�6y certify,Ihut lire a e11(sJ ta'as imere)abandoned ire
!unary iaarrcl Wffiit'kltloa .INNI dovardalace Iri1Ji'IS�t.hC C=01, .61tf�'ur 2Cr 0200 DWIGv.mvliuctiufr Sfauikrrds
Hurdlkntricopy of1hisrecord has been.prioviOedfa kaarellouiaer
Sb,I-;tti(dde and loh9ltude.J0,degriceslminttic's/secotids or dc'elmal.degrecs.
(if�yarif tci our 4it11naa is tnitieeca t} 9.Site diagram or additionalveil detalls:
Ya3u inap.tlse the back of il►is page to uio•idz'additioual!sell Ai[g.a3etai"'ost►ell-
35.263786 81.005646 Ny :;ibaodonntet1&(oils. Youta#Aa oa16ehareiiiGoi:al`pageslftiecessaty_
COhfiTRU(..MOtNDETAILSOF%VELL(5)BEIN('.ABANDONED .SURNItT AT.iNR_TRUCrtONS
Atfi;dr 11A rarab-irctrclrt mcvrd/r)Jj m riiliePila •F4"mul(ap+e ugedi*rir rxrn•uuru-aarpplj,
irr1130YLYuJl/idr svruerorcttrxieomSLh�rrOranicut.j+surnnsaiLmiawrrfernrr, 10;,Far All Wclis• Submit tl>�fomt:itiittvn 30 da}`S afcotltplction of u ll
w-38. andW6tiurcal td tho folldwing:
L Nell ID#: i
Division of Water Resnnrcea;Information Pructw.ring.Unit,
6bcTatut well.dcptJt: 40
1617.5"il'Sci iee Centcic`RalciLb NC 2709=1617
(ft:) :'< t. +. .
lOb.Tor inlcelinn Wells: hi.addilioa tti ndiug tt1K foam to tlae addtrss in IOa
fie Baacitale diameter 2 . above:also subath one ciitsy of iris form within 30 days of completion-of well
(u: abando-Unacut to tbe;follniving:
I
Division.of Water Resources;Undeargronud Injecilou Control Pr6gram,
6d.W itcr Fccd.betow prbttnd surfaced 0 (fr.) IG3e,Diail Seines ten l'i;Italci;h,NC 21694636
Gc.4utcrcasin£icnrth'[ilPimolro}• .35. . . (fg) nc.Fnr Warer.rginnty&iniectfon�V".I�t: In addition to sending ibefonta:to-
the address(esl ablite. also submit 660.,Opy of this'fbrm-Wk iin'36 days of
completion of Awll abandmnxtu to the county Faith deprrtmet8 of the county
6E InnerCaNiu„ftnbiug lui}Kh(if laiosvn): (fL) iilacrc 1b,ntloncd,
ft Scmen length(if known):5 (ft.)
Form W-10 Nanii Camilm Det>;urmcm a1'Environment aui Nntuml Rcso=es—Division of WatuR, re.3 Revised Ajagua 20 U
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WELL A:B ANDONI I'RECORD >arin,Jo Jtiv oriLx
11tis foim can be used fodsingle or mulliple rt eft-
➢.WcgCnngact�r.infortnutfiii>: UTLL AU&NI36Nh1ENT DET'AI1f:.R
Scott,Hunt Jr \7a.Nuanberafm4ls being uhjutlnknci6 1
�Ycll arilraciocidanJe(graYill oAi J_rpisaaatl?iJliaiiilruinnuiilogr'tdsllJceprupeey) /1 1ai .nlutfiptn G{Ja Jtar w Jvnvl`:Jter suppo �+vr4s'. DVEY wai .Jle saita
iA/ €4/d3fFifCfllNl/i71CafJl.Yr'fNJAJ�TlIt,}Y!f![3tLP 17J�!1JIit fNJsJfPI'AI,
4561-A
NC1Yc0CwJtttctor4ftifrcdl3oia.NaiJ�bcr ?b,Apprntlinsitcvrilnueeo[isrtut �centaani» in"tiellC:r}t.
'FOR�VAT.ER SUPPLY 1VEt LS'bNI:Y,•
SAEDACCO .
ConVany Name' . N.Type.Jpl ili�infiefnut usei0:,
2..Wd[Conk uLtiou peiinu#.500000ti7, �
LJstt�trlt�lhxarl•urll rJyreit1.c Cu1JrJt,SGx,I"Jriarrae,trri� r•i+7E
i1 � t 3 .J �. lgJ,4ituJsn ?Q:.tiriotttilrif:tiisinfeet:iat•ukA:.'
3.wett u»r(eLC&wc11 Use}:.
1Vatee Supple VVetl•_ 70.Saalitog 4rMedals:tascd(cbcicka.Wdiat aitply); `
prtert.iiihual'. phpitnieflZ�!lPtt[�Eic M Neat CemcoWttat A goni©nitc Chfts orFcilcts.
bf3mlbcnwt(H4aling?Ciaoliii Supp!}) gltesidomisil watcist pnts.(single) 13 ward Cirutenl Gtnu1 O Di Clsy
❑kdastth'W's ntca[_fal pRcsit ennui,%Vke,r Supply(shaitd)' 17 Concietc Paou4; t1-Daill.Cittiid -
t]Uaf tiJiia .. O:spec!1Y Gtut1t i O,Gravel. . : ,
- i -
Ncrn=\VateP SuiipEc SVctt: 17 Beptottite 5lkft, O Other(eaTlaintinder 7g)
i A1u1tiWrtne P9ReJ uteta' '
Rnjcction lVctt� -7f For cacti tuile&iI sctceted abaF;c,p06e7dc amoteutof:mtt(Aat used:
bAquffer'LteclJae borounda;tlev'RenteJiiittiJ}m Neat 6em.:500lb ,Wtr:30ga1., Sand Cem.:lb ,Wtr:gal.
OAquifir,Stoiage awtRecoveq OS-Aiuity Wnicv
OAryuifs 13Slonm-14teiDini0ge-
17EyacrzmeiJt i1 TJ clmotogt' t7SubsiJtellCs GatMm1 7g.-Pjp Jvfdt a hrisf 46e- ipnnn of the ii tnatnnmm'ptrvtccrlurc:.
C1Geotkennal(Ctoscd Loop) OTracer
trimie-,grouted bottom to,surface
OGeotheniatilieativa)Cootin 'Return]' . : Mlher!�lninunder?R) . . .
�:OitCtFCII(5),J21aI,�d011Ct 7-17-23 !AU6 2 $ 7093
Su:`�Vell;[nwtiou: 1Nt2rrM-�'iCn�J•rr��a,��t Ina _
Motiva D1P'iOMOG
$:Ccrdit�eedou:
racilt�7'Gtvltet•NaaJJc Lacililyt1}avft'applirmblel
6851 Freedom Dr. Charlotte, NC 28214 7/28/2023
Physical Addmss;City;aM Zip $t gJJn orce:tim Wa Cuuutctor s;11 Owtur. DiJta
Mecklenburg. F�yr�PgiaPlig_�k±s„JPrlytt,;.f lre7teby caw Igh,IM21 the waflf.4!H'Q$.(IF"abarJdoned hu
(cJuut� Nreel IdeJJiMmWit No;WN) frizbnfkJJuc with-hu Alin e k:01019 or'C.0200(Fell Consi3• cdon-Rantkirds.
- rlridlirrita'cpP}oaf'!/rirrecrJri�7tazshee(q�pJiovic'ecllotlecircllorvJler,
Sb.Latitude and:loitgitudein-degmestattiruteslsec6ndsur'di inaal.tiegrses:
tlr.,4t1 .t�l,'or+cllt irlg siJtrit a) 2 Sitollggiunoiad'dId6nalwdtdeiAlls:
1'6u;iu i�use-ed a back of Iltts page to provide addMonal ttell site,dztails or.icrell
N ' abandoimteturletaits: . Gummy itt'athii:h iWifivaial,pages af.tad�amt♦_
CANS CIt11C'1ldytli.DjR'CA➢kA OF WMILLIS1,BUNG AflAll 16NED SUfihiTf'1'Al,iNS f1t1 iC FiONfs
:tfmvh irdt m a�mw1kia mcmd(Aj ij`mv3lrufo. fir JrrJJ16ok,:HJJrYrlrin rJr rv�rnuxJlu slrppf I
Ytx'lId OJY Y IJ•1t�J the.557.UMtGIrStJztttlulNrLri�lr7G�JN1J1CNJ1:_l+Jtl can-wiJJJJntd Wteforir�_ 1Q4::Nnr All'Welk: Submit ihUs'fgmt Withini 3tl 4`5 Jaf Coiiiptction of ti-c11
6d W e11 II1£I.RW-3. abandonment to the Callowi : _ l
EIEiisinnof�F'gterlCasniacr�;�Inf�a-%ntinti:Proc�siiabYTnit; •
1dt7 Afail SCPVIC¢Center,Iia1cE*li,lYC 2^,t.19-161
611.TotJlt kill IIcEiCia:.z 5
toh.boa`t"Wooiort Wells: hp:Iddilioa to sending lbe form to Itle address In 103
fc.Ii 8 (iu.)
aboUr,also submit otte iopy of tliip 4'ona i%iiltin 30 buys of compteiiott of well
ortyitolcdtsutOei: undtm rbotcnt to the fallon•iug;
frtl.lS''aver.tccclbeton:grouteslstiefatec:.10 (ft) 116visiotaoflVatu°Idisout9c�4 todcigrouutiltt)e�ttonContavlPtvi�ii,m,
1636 Rfail.Sccvicc CentIcr,Raleigh,X .2 699-1636
6c Dutcr casing IEm 6 Cif.lancs n): (fw) doe Fna�V tter•SunnFr. lniecd(im 14'e1Bv vat 1cldidon•to sending the forth to
the.address(es) oboW.also subniil one-cop} of this'fatrn'tvitliEn•30 daps:of
conviction of vcdl sbandJiaaatznt is the count}•iteslith Jlepanmcid of the county
6f.1flRrx.c arin[;&Uhia;;lough(if[neatin)s (ft.) whets abaridota d,
ft Scr&a length(tf]atom, ): (ft:) f
Pan a GA,140 Nonh Camlim Depadn ew of PnYfeunrnei�t JrJx Muur�t Resawccs- Reviscd'Aupau 20B
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{ WELL ABAND.ONN ENT RECORD For Irderrlal Usd ONLY:
This form can be used for single or nudlipte tcetls
1.Well Contractor Information: WELL ASANDfINh1ENT DETAILS
Scott Hunt, Jr 7td.IVumheri►f.wells b'eini,ahand tined: 1
Wel[C'putraclorNante aruclfotvtxr tsdnall ,laandanin�wail.nnliL9llt;r ru n Fdr irmloplc, fiyeelfo,r or zala,n'Better supply wells .ONLY wffl, rlre Sarre
( �' P 9} eaa"srrxcriwa�abarrdrNrriraat,3nr+cr,ariA,'Ntarefonn,
4561-A I
hTC Well Caulmalar glficalion KutrtEtcr 71).ApptnximAte♦•oltime of ttattilrinawning in tvell(M).
i
SAEDACCO FOR WATERSUPP.LV WIiLLS,OI.11.Y
I
Cong,an}Name 7c.Type ord.hinfictant used.
2.Weil.Construction permit 0-50000087, ,
13at ell appflcYlbl�.urfl permtrr,(ie Cwr,ly,Srale,i'urtriure.Lrrecflou,.ele}if 4,ruwr�• 7d.ilititia[iI of dlslnfictdnt ttmtil:i
3.W 1 use(ehedcnell use):
Water Supply Well 7e,Scaling materials used(cheep:ill'that apply)..
prlprirulttital plvittriicip tllPnhlic Do Neat Cement Grout ❑acruonitc Chips or Pcilcls
00cothcruvtl(HcatineCoolino Supply) pltcsidctuial Wafer Sitfttply(sin�nlc) O:Sand cintent Gmut 0 Dry Clay
ClhidtrnrialfCommcrcial ❑Rcsidentiii Water S)Ipnly(slvuo) D:ConcreteGrout ❑Drill.cuttiags
❑Irti lion ❑Speciolty.Grout ❑_Gravel
Non Water Suppky w'cll. El Beptonite Slurry 0 Other(explain under 7g)
❑ManiWriiag 1.911e coveq
Injection Well: X For each material seieeted Abovi4provide amount 6f:tnaterials used;
l7Agu4ctRecb3rge ❑Gr6Uhdtt7jterRelnedivtiaa Neat Cem.:1501b ,Wtr:154a1. Sand Cem.:lb ,Wtr:dal. .
f7AgniPer Storage atsl Recover' OSaiinity Border
❑Agnifer l'esi OStomn�uter I7iaitwgc
pkxpmonenlal Technology ❑Subsidatz c CotMtnl 7 proiidea hriddcscriptian of tnc abaudonmcnfliiocW.urm
00001hermal(Closed Loop) Mracer.
OGeothenttat(EIeiiGn Conlin Rdum) . ❑Other.(eti lain under 7 ) .
trimie grouted bottom to surface
3.Date we.U(s)abandoned: 7-17-23
Sa.We0 location:
Notiva Iraft3rtfl^,�;l;trr'r^t. blur
8.CertiQratlon: +
racilityfflivncrNumc racilftti•lum frapplicablcl L r Wta
6851 Freedom Dr. Charlotte, NC 28214 S�ie�t ! ! 7/28/2023
Physical'Addms:City.aid Zip SiAmtarc ofCcrtilied Well Crtur "or or Writ(hvrur. D:uc
Mecklenburg, 13}+sig�rhig this frnnt,I Jrer�by_rertlfy that the at•ell(s)IM.v there}abandolietl to
County Parcel I&HU&Woft No;(PINj accortlance tvftli I M:UC 02C:0 .09.or 2C.0200 WrIl Oohs vdion Stnarktrds
and ilrat a copy ojthfs recurrllras been pravid&,fo 71re isell owner.
SU,JAMude and loogituttc in degregtimloutestseconds or decimal degrees:
(ifaetf r`4td, 9.Site dhtgtam of additional well'deralls:
Y6u ruby use.the ba&of this page'to provide additi0aat viceU site details or-Well.
A� W abtindotuttent details.'You may also attach addificiud pages if ttecassan,..
CONSTRUCTION DETAILS ON WELU_q`L BEING ABANDONED SURNTU PAL iNSTRUCTFONS ,.
Affadr»rU romm'9cfiun riror�tt.J if awoi&U . Fur mntLplr.irtjrctian orruln•nvrrr.supply
dNLI v ith rlry scrim ansburrlon'afi'atnk,rm�utt,i x1 ern�,rLmle ww firm
10a.For All WeI1c: Submit intsi foiat irittpn 30.dx}`s af.complction of arll
6g.tYell JDO:TW-2 abandoninctit to the foll6lving:
I)Msioa of}Vrater Restiurcts,�Information;Prgeming Uniti
GU.Total iscll depth: 15 {fY) 1617 Af M Service Center,Raleigh,XC 27699-1617
lob.V Inlection Wells: In addition to sending the form to the addrrss In IN
above,also submit ow ropy of this form within'30 Aays of completion of well
6c.Bore diameter 6 abi ndonntent to the fallawiug: -
fid.lNatcr lc�cl below' nd surface• 10 (ft,) Division of W,aterResources,Underground Iiijietlou Contriol Prdgratn,
t 163611tail Seniec Censer,RAlcigr,NC 216994636
i
6c.Outer casingtcngth(if known): (ff•) 10c.Fnr Water Surlily&iniectfnn'Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form wigtin 30 days of -
comptction of well abandownent to the•counly Ibmith deptatnicid of the county
6f.]tuner ctsinf:/tnlrinf;trngah(if tmown): (ft.)
wfcm abandoned.
6g.Smvtt length(If known). (fL)
Fa nt GUY-30 Nonli'Carotim Depanrtx;m afEnvironmrnt mA-Narumt Resoumes-Dtvfstanof Water lt6oumes Revised Aagusi 2013