Mecklenburg_Well Abandonment_20240116 (5)

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WELL ABANDONMENT.RECORD. rorintemai use'ONLY:'
1.We1LContractor Information: WFLL ABANDONMWr OFTAIL5 1
Don Warren. 7a ForGeoprobe/DPTei Closed=LlopGeo thermal Wells having the saine
WeiLContmUor Namc:(oravdl owner pcisomlly.atrandoning well on'histher property). Wel l consttuctiori/depth,only 1.GW,30 is needed Indicate TOTAL NUMBER of
3581-.A wells abandoned:? I I
NC Well ContractorCertiftcatien Number 7b•Approximate volume Of-water remaining in well(s): (gal)
Mid: South:Environmental FORWATERSUPPLir•WELLSONLY:
Company.Name,
7c.Type of diiisinfectarit used:
2.Well Construction Permit if j
Lis-aid applicable well construction permits(Ez UIC.County,.State,Mariana,etc.).if h7owlt
7d.Amount.of disinfectant used:
3.Well use(check well use): .
Water Supply lVeM .76.Seating.inaterials used(check:ill fhat apply):
❑Agricultural ❑Municipa!/Public s'Neat Cement Grout- ❑BcntoniteChips or Pellets
00cotheanal(1Jbating/Cooling Supply) ❑Residential'Water Supply(single): 0 Sand Cement Grout b'Dry Clay
13.1tdustrial/Conunercial ❑Residetttial Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Ind ation. 0 Specialty Grout ❑Gravel
Non-lVafei Sapply.Well: ❑Bmtonite.Sltuty. ❑.Other(ex:plaat under7g)'
mmonitorimg: ❑Recovery .
Injection Well: it For each material selected above,provide amount of materials used:
❑Agttif&..Recharge ❑Groundwater Remediation- :751bS grout
❑Aquifer,Storage and Recovery. .❑Salinity Barrier
bAquiferTest. ❑StonnwaterDrainage 5 gal water
❑ExperimentalTxbnology ❑Subsidence-Control
7g.Provide a brief description of the abandonment procedure:
❑Geotlhemial(Closed'Loop) ❑Tracer-
❑Gmthemtal(Heating/CoolingRet►rn)- .00ter(explairt-ttnd 7g) 'Per 15AMAC 02C.,0113.(d),.a band 6nment:
12/2 :was completed by filling the well with.
a.Date well(s)abandoned: .7/?023 _.
Portland dement.
Sa:Well location: j -
-Woodward Avenue.Site'.
Tacifity/Owner Name Facility IDN(if applicable) &Certil•''How 2
:1022.Woodward.Ave;.Chariotte, NC.28206 Rk w t,1- '12/27/23
Physical Address.City,and Zip Signature of Certified Well Contractor ot.Well Owner. Late
Mecklenburg.
B},sfghing this fonn:Fherehy cerNh,.that the irell(s)-was(were)abandoned in.
County Parcel ldentificatioriNo.(P1I�. accordance.*ith•15ANCACO2C.0100or2C.0200'A!ellConstr7ictiox'Standards
and that a copy of.this;record has beer)provided to.I&hell ower n ..
5b Latitude and longitude In detirees/minutes/seconds or decimal degrees: j
(ifwell,field.'onc lat./long is sutticienQ' 9:Site iliagrvnor additional Well detaDsi
35-14'5970" N 80-4.9'.56.56a. w You may use tie bade of this page to.provide additional well site details.or well
abandonment.details: You may also,attach additional pages if necessary.
CONSTRIJCTiON DF,TAii S OFWF.LU.%BFINe.ABANOONF,D SiJBMITTAL INSTRUCTIONS
.411ac)trdelleonstnrctiotirecord(,;)ij6r�ailable.7%ormttlfpleinjectionortion-watermippttviells.
ONLYivith:the same eotislnieGonlabancUnmens you can submit one form:
IOa For-AII Wells:: Subunit mis font within 30 days of.contpletion of well
6a.Well 110: MW-2 abandonntent.to"the followiig:_
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Division of Water Resources,InfornmtionProcessing Unit,
6b.TotafweD depth: 20•0 (fl.) 1617Mail Service Center, aleW4-NC27699-1617
0b,.For iniectlon'.Veils:.In addition to sending the form to'the'address in'10a-
6d Borehole diameter. 4.25' Cn). above,also submit one copy of this,form-within 30 days.of completion of:well
abandoruncm to the following: I '
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6d.Water level below ground suffnee (n) Division of Winter 12esoutces,Underground injeed Control Program,
.163611iail Service Center,Ralco.,NC 27699-1636
6e.Outer rasing length(if known):.10 ,(}t) 10c:For Winter Sunnly&iniectiim Wells In addition to sending the fotm-to the
address(es)above.also submit one copy of this fortit'withiii 30 days of coritpletion.
of well.abandonment.to the.county health department.of the county'mdicre
6f Inner casing/tubing length'of known): (t>t). abandoned..
6�.Scrcrra length(if known):•10.0 (R:).
FormCW-10 North Carolirua-DcpartmentofEnvironmenta'.Quality=Division ofWatcrResources I. Revised2-2114016'
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