Mecklenburg_Well Abandonment_20230828 (6)

WELT.;ABANDONMENT RECORD �
rat Internal tlss tmLl':.
This foam min be used for single or mttlliple tsells
1.Well Contractor inrerurgtion: WFLL ARAN DONNIFNT DETAILS
Brian Ewing 7u.Nanrlrer of n ells being abandon di 1
4PelfCot�ractnrTv�tue orrtil[utiresr�rSatiail rli�Qila»I +•rtLtlan9ris11; r rn`.n For midliPle hJeelfor wi non-mirer 1 step ,� aelLt ONLY with the se
F' 9) ccrrtrtrrrcrrirr,�rhlarrdrnirrr��rr,,trrricfvr,snr�rurrurejnrm an
4240-B
NC N4e11 Conhidor G:nlliadion Ninrbei 7b.Approximate vol.nme of statti ntaininl;iir Ai ell()t
SAEDACCO FOR Wrt1TFR.SUPPLY WELLS ONJiX,
Company.ltianre
7c.T�wYte of disinfictaut u;;cd:.
1
2.Well Construction Permit 9:50000087, +
Lt3l:Ill ralrl�llairbl¢irrNtrer rtitr rye.i"i r1r Ih.Slide;YaHarv�e.1ltledfu1;mill rj82nrrs11 7d,slmoutit of dlslufectatit used:
3.Nvrj I use(chceli A'va use,):
bvater,Sttpply.Well: Vie.Scalinb materialstiscrl(clyd0;an;tltiti appiv):
❑Agr(ctilturnl ❑lvituticipalrTitblie fR Neat Ccmcnt.GWI ❑ Acwovitc'Chips of K-11cta
OGcodicnnal(Hca(i1rg?CoQIl11g Supply.) ❑ltcsWntial 1VatcrSupply(single) ❑Saud Ci!Tviu Grout ❑'Dry Clay
❑h4vit"lCommcmial ❑RoOdentialVatcrSupply(shamd) ❑Concrete Giou( ❑Drill Citltiit€s
❑Uri tiou ❑Speciallt Grout ❑Gravel
Non Water Suppy}yell: rJ Benlotute Slurq ❑Other(espial,under 7R).
Mmunitorvm ❑Recntery
injection Well: 7f.For each material selected above,prwside ainmrnt-or matcrials rued:
❑Arjrdferitecharge ❑GriluirdtitiaterRentcdintion Neat Cem.•471b ,Wtr•3gal. Sand Cem. lb ,Wtr•-gal.
Mquifer Storage strait Rec©Vety ❑$alihity Barrier
❑Aquifer Tesi ❑Slonutieater Uruirwge
❑txpetinwn' rl Tt-clmoloev ❑Subsidetre Coni.rul % Prn•ide a brief d6cription of thcjubandnnment procedure:
Odwihennal(Closed Loopy ISTracer '
TREMIE GROUTED FROM BOTTOM' TO SURFACE
Moot ❑Other(es 1ainunder.7w
-- -- f T. i'-�� '_ '7
a.°Datc�scllis}atb;tndnnerl: 7-18-23 ~ I i,
5a.Wen lucaiion: 2023
Motiva rhCril^roili: (!�{
S.Certiliiatloit: DW o
Tatilitj/rhvi►:rNairx Ta:ilitpIDN(afbpplicabic) � r�%:a t�4i
6851 Freedom Dr..Charlotte, NC 28214 Brian Ewi"g i 7/28/2023
Physical Mkcs.City,and Zip S(�>ahrsc of Ccitttlea IVeU G!w.Y.Isli s:::tI CJ?�'tur 0;11e
Mecklenbur% Oyu mpfinr this-orur, I herrby cent fy lint 11ae lr'ell(.4) uvrs(were)uhmidoned in
Cauuty harecl]dcnlife IlnuTJo.(PN, occ'urtione❑dflr 1 iQ xvilc 0, .Glad or 2C,0200[Dell Ci+ sfruv lure Sliiwkrrifs
and 1/rat a copyofilds r emril has beenprioweed(a llre-tred Dower.
5b,Lttitudcand longitutle in dcgftestinlontestsevorids or diem al degrees:
(irx•rlt rant,oree haflnng iS nfiicseq) 9.Site diagr'ain or additional well details:
You tna},tie tli:Wcl;of this page io_04mide additional well site details or will
N Iv ibuudonnteeu details Yoti tuay also attach aaliiiGov tl pages if ixc�sary_ '
CONSVirkitpoN DETAILS OF♦WELi S)BEING ASAlIDONVD aUBAM At,iNSTRUCTiON,
:ttJrath 4rir$tnav4wc7liurr,-cruelty V',ai4ni eye_ ,Fur midaple BJiCiioie ur rvin-11xn'rr-M),
welhy ONLY vitli ilry avnre Caro srrbmrt wreFinrc lau. For All WclLa Submit t1ti5 faint x►ithin 30 tars of cotnplctian of a ell
6si.Wcn mg:SP-6 :Ibabdonmcnl to*(ha.fallowing;
Division of Water Resourci+s.information Prowming Unit,
6b.Total well depth: 25 1617 Mail Senice&n,tcr,Rale'iy;ti,NC 27604617
IUb.For Inirelion Wells: In addiliou,to sending the fotmao the address-in l0a
roe.-Borehole diameter.
aborx;also submit one copy or this form ss'ilhiit 30 days df corpletion of well
abatidounteut to the Fallduirtg:
Disision of WalerRcsnurrO,UndeMiround Injection Contral Program,
641,Water tcrol be[*ground surfacot M..) I63f Mail 5cri+icc Ccntci,Raleigh,NC 276994636
6c.Outer casing length(if imnn-n): (ft) Inc. To-addition to-sending the fomt to the address(esi above. also submit one copy of this torn within 34 days of
completion of vvell abandonment to the rnunly it 111L dcp uncut Of the county
�vhCrc abandoned,
6E Inner easintt/tubi,;;length(if 1wown): (it.)
i
6g.Screen length(if known): (m)
Farrar GW-30 NonliCa.wUm Depantne.w ofEnviionment aril Mimi Resourets-Division of Water Rc.smuces Revised Angusr 2013

I
WELL ABANDONMENT RECORD Far ltAantalWcs C i.Y:.
This f9imcan lie used for single or niulliple vVells
I.Well Contractor Infor{notion: lY>LL ABANDONMENT DETAIL.%
Brian Ewing 7n iVitrrillcr of�raslla Ifeiatg ulfaudnned: 1
4?'elt'4'oursctorl\an� orualloutur �iSariall ti�ettdt �sclldnJtis7(ttruu �n( Far trnrlaple tnleeJlar Wr con-Hier, 3,rptdy watts ONLY 01b Aw sra�ue� t
e�+raerrvcfetxui t„i,riiniitm�af,,iae,eiiur swhmr iv,00rtn
4240-B
NC Wc11 ContradorCen lfiatLitiu Niivabcr 7b.Apptn..xinrate vhlume of grater r airing in it�ell(a); (• d}
i.
SAEDACCO 1FORAVATF-R_SUPPLY WELi.S ONLY.
Convam,Nano 7c.Type of disinfiw-tpnt oscd:
1 Well Construction Pernitt#.50000087, �
Liv id]q,Ii lydbte,rXOparMAi[i.e_Co¢,r.j',,Store;Yuidiutie,LrfrrNan,N1c:)lJ4t,uw�r 7d Amount Oftllslnfestant'uSed;
Water Supply Well: 7e.Scaling hi terials uscd(cheel;all that apply):
gADri ulturot i7hlinkipaVPt1biic CR Neat Cenlc01.G(6tt 11 Bcntonitc-Chilis ofPcllm
gGcothcrmal(HcatinglCaalinD Supply) ❑Rcsidetnial%VatcrSuppiy($ingic) q Satin Cemeiu Gniut ❑17ry'Clay
glndo5trialfCcimmcrcial ❑ResidentialVatcr Supply-(shored) ❑Concrete Grout ❑Drill Cupin95
❑Irti •tiou ❑`Specialty Grout ❑Grivel
Kon-W,atcr Supply Wclk 0 Bentonite Slutay 13 Outer(explain under 7,g)
[&Motiltadite gRecoverV
injection well: 7f.For.each material selected above;provide awoaot•of waterials used:
❑AgniferRecharge ❑Gromtd-a-WerlRetucdiatian Neat Cem.:471b ,Wtr:3gal. Sand Cem.•lb ,Wtr•,gal.
'E3;Mu1:&r Slon(ge and Rtwbveiy 13Salinity Barrier
gAquifer 7'esi OSlonnwater D}uivag,:
❑Eeppriutenlal Tixluuflogv pStiUsidet>a CoiNtul q*Pmvidc a brief d6cription of the.uhandunment p"wedure:
❑0agd renal(Closelt hoop) DTmcer
TREMIE GROUTED FROM BOTTOM;TO SURFACE
®Gcothennal(HeatinYJCootiar,Rem) C36Nr.(e_\ lain under 7p,)
d:Dafctvcr[(s}.:ibandonelt; 7-18-23
5a.`Yell lucatiim: O
. - r
Motiva �(,r,si
Fati]itjlt7r,tr:rNutrcc FacilitylDN(iCfipplicablc) $•CetrtiRcat(aii: DVG`G)ir 0v
6851 Freedom Dr..Charlotte, NC.28214 Brian.Ew ,n 7/28/2023
Pln'sical Address,City,and Zip- �Etcttlnro ot`tx;itt9e�t Xb'43t(a,urrk,i.r-ei 4l Ovwr
Mecklenburg 13y siring rhts jean, 1 h"- certify Mar the irefl{s)was pwe)abaudonrd err
Coottiy fsarccl l&WEE61ionNo.{PiN) -acvvnianCc with MA A' -IC 42C.0100 or 3C.0200 fr?ell Cirris7n1r1lu,,r Shimkirdi
and 11ral a c6piraftlris record hushwo pravit'adto dumvell on'ner.•
Sb.I uihlde'and lmlgitu11011 tlegrccsfln9nuWsAtco0d5 or decilnld 0gtrces:
(iftrcn fold,cii,e 11t1101tg'.ii altff3e*iely) 9.Sit►diagram or'additional weil details:
Yau•utay.use ilk,back of'dits page to}t 6Ade.•additional isvll site deriils or will
>t lY :6andonnient details. 1'ou rasp also aifacli adiiitiotwl pages if ttec sas♦'_
C(►N'StR1H" ION DETAILS OVWFLL(S)BLtiN(:ABANDONED SUBAi111TALtNST1RII4C.Ti0N,
.fffadr uvll t'orxrrruc'i1Wt ncvrelts)Jj'.aialharile ,For m„Irrt,le injevffii r or win-nruer:,;upply
utillez ONbY m1fL 11re awu r�niirserrirn:ril arnforrnenf.�+JN Ct]fiS1f MII.WPeJF,f12 IOJ. For All Wells: Submit tbi.5 famr ifithin 30 dkVs of c6niplction of ivell
6,i.Well I6#:.SP-5 abaneonmciu to lira al9owing:
Division of Water Resources,Inforru'Aim Proces.�ing Unit,
1617 K-41 Sense Ccatcr,Ralei-gh.NC 2760-417
6b.Total well depth-. 25 Ay
Ipb.For Infection Wells: tit addition.to sending the fprnt;to the addtr.ss In(0a
fie.Ro>thole diameter.1 . (iy,} abow%also subudt one,t6py of ihis fbhw.%ifliin 30 days of cmnptefiou of w*ll
abatidounteut to the fa.1161,'ing:
.Dhislori oflM*iter Resources,Undergrtufud Lijcctlon Couftvl Prograuu, -
tl,Water tcvci'below grw6d surface: {ft:) IG3�111ai1 Scrcicc Ccntci,tt rise;h,KC 27G99.IG3U
10c.Fnrly-da 5113plv.k.inigrfinn Wells: Ill addition to sending the fanttto.
Ge Outer casing length(if lmnv,'n): (ft:) the.address(es) above.-also 86niit one cops' of this tbtmt evithin 30 days of
6ipptctioti of tr�ll abandonrnent to th'County health department OF fire county
Gf.Linn uryiny!/tubinp ten}Kli(if laiown): (ft.)
t'vhcrc abandquc'd,
i
6g.ScrCCtt length(if known):
Fomi GNV-10 Nblffi Camuna Depannx.m df Pm'irowent at%]N;auroi Resooues-Division or Wa[cri csowces Revised h,tgus 10 t3
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