Mecklenburg_Well Abandonment_20230828 (4)

WELL ABANDONMENT RECORD For[Mcm.I Usu ON-Me
'This form cairlie used for single or multlpla lvells•
1.Well Coutracior lnrorniation: 3YELL.ABAND6NMENT Df rAsL%'
Brian Ewing 7a,glummer of n ells tieing ahkidaircd: 1
til'c1t'Coidraetofl\anM orireltuwrsr`•rSa)i�ll awn,hi uoilonkdsAter ru n For' tnukrj,le tylerilar 'or' rb,rr-ii'riterl ; rpj# .wells ONLY wub Mw sm„e
( R y' [? pe y) l
.. - Cdil3f/rrctl(Nl;(1�,a�Ylruir71��r1f,Intl a mi.Tiir4,11f twiefrrrm .
4240-B
NC 1Ve11 ConingvrC,ulric�lion Niin acr 7U.Appm.,.tinwte'Fa.cite . titat gin Atiell(s);
p.
sAEDAcco �FOR.WATERSUPPLY.NVEGx.5b�rv:,
Cams ug'!anio 7e.TS7te rif di5infectant.died-
2�-Wcll'Coustlucdou Permit 4:50000087,' ,
LL�l id)uliplhvRe i,xB permits.ti.e;Gr,rfi'.Sr,re:!nr{ur Ce. ?d:Amount of dislnfcStant used: 1
3.�Vrdl use(ch'eclh'cll uSc}: �. .
Water.Supply.Well Vic:Scaling mutcrials dse+l,(cbecl"all Wat apply).
I]A iicirlhieat j7h4dnicip:il/Pub1[c rA Neat Ccnicni.Groalt C7 13cravnitc Chips yr Rallcti>
ti3cotltcrm411l Olcltinvcooling'$upply) ❑Resod,-mild Water S (5inG1G) V Sand Ceitieiu Grout ❑Dry Clay
❑hidustriaUCommciciA OResidetuial Water Supply(sNuw) ❑Concrete Grout ❑Drill Cuttings
❑ini tiou •l7 specialty Gruu! ❑"Gatvel
Nap--Water Supply Well; t7 BeittvnlEe 51urry. ®Other(explain under 7g)•
�Mariliodne ❑Recotery
Injection Well: X.For.each material selected above,provide amount'of waterials used:
❑Aguiletltccharge ❑Groundi�alerltrmerinition Neat Cem.:471b ;Wtr:3ga1. { Sand Cem.:lb ,Wtr:gal.
l7AquiPee Stntuge aixl E2ee4�'ery' ❑Salii►ity 13arder � .
13AggiferT4t' ❑Sivmr}t'ri[erDnrin ge
❑EWeri(itenlal Tecliiioloeir []StiUs(detxc Curtltril 7e,,.Prm•idc:i bric-f.d6triptian of the nbanelonment prricedun::
❑G.aihermal(Closed Loop) MR.acer (.
TREMIE GROUTED'FROM BOTTOM�TO SURFACE
®Geothermal iHeaunpJCoalinAReturn) ®Othortex lainuodee7s)
EVE
7-18-23
J.DatccU(s}:abandoned:
5a Well lua'tiim: AUG �119T
Motiva
$.Cciti(Icatioa: Irl{�r)19ct.,1
P'mcrlitj'lO,vrxrNuirtc rxi)itdlDr'CfSpplica6lc) i ?r;;,v,,c?q UthV
6951 Freedom Dr..Charlotte,. NC,28214 Brla1�:._Evu11'1 7/28/2023
Pin'sical Addtes.Citf;and Zi .11 Qisn:r D,qe
Mecklenburg By vigining this JOrtn, 1 heraby certiy4hat(Ire rrellfs}was(it-ore)abandoned in
Couutj' IrarLClldaruifigidOnNa.(PIN). nor,'vnifinwirith MA MIC b2C.61U0'or•2C.0200 I.Mell(7viignecuoM Sf6 niknr(ls
agel drot ri cop),flhis morel hay been.proyisrarllo dre-well ou'irer.'.•
$6,14ili rdeand longitude in rlemeshnirraics/seconds ordeci i-AACgrees: I-
(iftr cu rm:K ova iatilniig is ,tiiic i>ip 9.Situ diagram or additional Weil dctaUs:
You.ntay:we the hail'of'dris page to{iroWe.:additivnai tttll sitt;.det�ils or Hell
:abaudottniQtn details: Oii tau}'also altiA iddi iioual pages it rieccssary_
CoNSTRitCIrION DETAILS OF WELL(S)BVIN(.ABANDONED SURNWrTAi.INSTRUCTIONS.
Wadi u�ll tnra hwe.1h,n iiLYMI(g iJ',(irdld 1e_ .Per Amfolik hyiedhi u nr rtt:n•nrtrir auppl}- I.
wellsO:VLYvJfl,rhersmn�'en,nhnrrio,r.'ryioreek„rr'feral.;t�aeairslrlurdtri,rr)Finri Mai For All Neils: Suhmit tbii fomr iiitlun 30 days of completion of u+ell.
4 Well Q6#.RW-10 abandoltrncnf tQ tha.fv114�ving; �
Dtyisinn of Wal&ffisonrrai�,In6rna thin Pr¢res.Nina Unit,
W%Total well depth: 21 ([t,}- 1617 Niai1.Scnicc Cents ;RAktgh.N 2769 9-1 6 1 7
IOIt.Fvr Inlecllnn VPells: In aridition-to sending tli forth to thi address to l0a
Gc.Borehole iliadtete6:4 (iu:} above;also stibniil oue ci)py or ihis fo m:Mthiu 30 days.cif cotnoteiiou of►well
abiudonnictii to this fallatviiig'
.Division of Wiiier Resources,tlpderground Li jgctlou Control Prdgratu,
Gd,Water leFxlJiclow ground surface: (fr) 1636 119tai1 Scrsicc Cent ci;ILilcigb,Af'27G99-7G3G
Gc.9uter:ca3ing Icngth(iflmon`n); (f�) ltle, Cr FnrM!gr. i[!J)ly tnieetron Writs; In addition to sending the fonudo
the:addtzss(esj above. also.sttbmit hue copy of this flint Within 30, days of
completion of vAl abandoini ru to the count}'he:ahh depadnicid ty*
of the coun
ivliero.;tbai►daricd,
Gf.Inner e0%inWtubiuN kn nth(if lmo{Yn):
6g:Screen length(if known): (tlt.)
forne G1Y-30 Nanti Corolla D.tnitnrod a!Ent'Ironmcnt ai�i N:uuial Ilesoic2cs-Qlti'fston of Water Rouw�s Ravise l Auw.q 2013

4
WELL ABANDONMENT RECORD rat Imcnxil l w ONLY:. �
This fomr;an lie used fbr single or tnulopte icclls'
1.Well Contractor 1nForluation: 1VELL ABANDONMENT DETAILS
Brian Ewing 7:t,Numi►er of,wells being allandu led: 1
%Veil6utractorhaut(or well,owmr►xrsiriall) d��nlaottcilonlustl1 rprupcny) For widOFle 1r�crtiar or rvxa-ir'ferl sirpJd), wr+lL 01rL1' with Me sonic- emrxrrrrcUtnrrt4a��ltrair.t�2at,trrei rursate.tr ra'refrrnri,
4240-B
7b.Approximate volume of water ninaining in iwll(s)i ( rl)
NC Wull ContmdarCcttircadiou Niirnbct ,.
SAEDACCo I'ORWAT ASUPPLYWELLSONLY:
Coat an}[tianto 7c,1igie 6f disinfiYtaut rtzetl:
2:NVell Construction Permit 1!:50000087, ,
lift dill U}i}alltvfdeurll}nrmitr(Lr_CoiWrh,Stale.{urtivrte.lnfrdrun,eJe:l Pfbertru�: 7d,AROnn10f dlSlllfCCtsillt nSeii:
3.Wri use(cligk.well use):
Water•SuppiY Well: 7c.Scalingriratcnials Owl(cliccl,all that apply):
❑A�ricnl((►r rJ l7htnnicipalll lbl►c 13 Nett Ccnicnt.Grout ❑ 13monitc Chijis or Pellets
1:14mtttermat Supply) OltcsidrntW Water$ripply(singic) ;❑Sartd Celttent Grout ❑I7iy CL•ty
❑Ita mifialf0 mtnercial ❑Residontial Water Supply(shared) ❑'c'ottctete Grout ❑Drill Clltlitip
❑lni tiou 11-Special[;•Grout ❑:Gravel
Non-Water Supnh•Well: ®Bentonite Slurry ❑Other(ea-plain under 7gj
113C141an11UrhiL ❑Recaver•
injection Well: TG For.each material selected above;piovide atnountaf.m:iterials used:
❑Aquifer k1cefi r;c ❑GrIbundipter Rented'ultian Neat Cem.•471b ,Wtr•3gal. Sand Cem.:.1b ,Wtr•gal.
❑ahuiferStorage Fuxl Rec©ven; ❑Salihily Barrier
❑Aiptifer Test ❑s lonns6ler Efruinage
❑Egreriruental tbcliuoloev ❑SuUsidet>L�Curc4tul 7„.Prnitidc a brief description of Aii alwidanrnent prikedurr::
lSGeoihenrial(Ciased Loop) bTracer
TREMIE GROUTED FROM BOTTOM TO SURFACE
®Geothenual(HetiD%'CoolinaRetum) ©Other(ex lainunder7g) .
d.'natewell(s).abandonedc 7-18-23 k
AUG
$a.Well!oration:
Motiva OvVcve cin t+rl Lnx.
raclfty10v'ncrtliunc rxlnyIVIJ(il~upplicalilc) 8•Certiti6tioit:
Brian Ew n
6851 Freedom Dr.-Charlotte, NC.28214 o. 7/28/2023
Physical Address,City,and Zip, Weil Cwuatcti,i e,�r.';tl(h+'rvr .D31c
Mecklenburg 'Hy signing this farm, I hemby w-ffy'rlrur the u•a11(s) wqx(:ere)abandawd i+r
C'aoaU ParectldertdficallonNo:(PIN) nccordiittccivithISA VJC01C,0100uraf_':#200I'MellCnitstnwffanSlanikeyAc
flat tlral u Cgpl r oftbis recorcl has beegp"row0ed io the-t+•ell owner.
Sh.1-itihidc and longitude ln.dcgmscstnunutcv/scionds or dscin)id degrees:
(ifnclt raft!qtw 4�Nnit�itstttiieaCrrl) 9.Site diagram or additional well detalls:
You may.isse Ilk back of[Lis page to.provide additional well site devils or null
1\ W daandoumertt detaiL�. You
!nap also vtacb 5dditioiral pabc s if rrecrssan_
CONSTRUC"PION DETAIL. t1N WELLS)BEING:ABAND(/NED 5UI1N rrAi..iNSTRU M. ONS
:Itfadi mifl cnm"efen arordit' 1J'ur lmfilrt ,Fur ninkipL geaiui[or -PPIJ.
welh,ONLY u•11h11rs,Lr,arnicsOvxlimr'aLurrrhmueul.iwepnsirumilairefiJnrc ;0a. Far All Welk: Suhmit this farm �rithin 30 dat`s of eoniplction of rtclJ
du.Well li €#:SP-3 ablindotttacnt to ft folluiving;
Dit,•isinn of Water Resnorctx,information Prirce.sing Unit,
66:Total well depth: 25 (ft.
1d17 mail srnice('cuter,Italeigh,ll C 27699-1617
10b.R-1 in feellon Wcllc: In addition to sending tle fbrm.to the address-in 10a
13arc1►o!c diameter—I above.also subndt one dopy of ibis R►nn%%idiin 36 days of cootpleiioo of we'll
6c. (iy') abandonment to Erma fallowing".
I
6t1,1Vater levCl below griturtd strrfacc' (ft�) Di%ision of Vlra filer Resources,Und6-ground Itijeetton-Control Pr dgratu,
636[hail Senicc C:cnter•,Raleigh,NC 27699-1636
Gq Outer casing Icnrth"(if Imnl,rt); (1t.) 10c.Tux W fifer 5unnly.0 iuiet•t►on l�rells: In addition to sending the font to
the address(es) above: also sllbuiit one copy of the-form Ivithin 30 days of
completion of vFcJl ahandornneni to the
6t*hC1C ahandancd• lcaiunly ltca[ib dcparintcrd of the eounh
6C Inner casinWtubin.tength(if lwwwnj: (fe)
6g:Screen length((f known):
I
Fotnr G1lr-30 Nooh'Camllrri Depamtxm afPnvircomew and Natant Reso=cs-Dlrislan of Whier RewILIC03 Revised AaguS 201_i