Mecklenburg_Well Abandonment_20240814 (12)

WELL ABANDONMENT RECORD �� rtrgcrtutll �C]N1}
This form can be used for single or multiple Hells
1.Well Contr•acair Information: WELL ABANDONMENT DE:TAII-S
ROBERT MILLER 7a.Number of wells being abandoned: 1
Well Contractor Name(or well ow mr prsonall)abaurlo"well on hn;et properg i F-(-r m,rlall,k• 01ROw11r r,r rw i-tt.tter sVrA weN, 0%'t.t ,r1, Nk-
cy+nrmrarlw,.rha,wkwro,,•ar.te,w e,m,wlvn,r w,r/i,rm
2675A
NC Wc1lConlwatrrCcnlficatiort Nntrthcr
7b.Approxitmte►olrtne of water remaining in welllsh (MAL)
SAEDACCO FOR WATER SUPPI.Y WFLIS ONLY:
Conpam Name 7c.Type of disinfectant used:
2.Weil Construction Perrdt#:50000079,
Lrr erll,gn(dhanl�•u�•fl lv r,rr,dr fl.e.<tMnh,.•}hae.I urJUM-e_Inlecttntt,eh'.t rf kmrtru 74L Arroraat of dlsinFectanl used:
3.Well usr(Check well usel:
Water Suppl} %kell: 7e.Sn iag materials used(check all that apply►:
❑Agricuhutnl ❑klunicipa[Public f) Ncat Cemcm Grout bt Hcntoniic Chim of Pclkts
❑(kothcrmal(Hcattn,,Cooling Supph l ❑Rcsidcnit:d Water Supph nsmglcl ❑ Sand Cement Grout ❑ Dn(fa-,
❑I dminAl'otnmercnal ❑Residettual Water StgVh isharod) ❑ Cotume Grain ❑ Drill Cuttings
13iffikWtion ❑ Spct.•ralh Grout ❑ Gratel
Now-Wafer Supply Wei: U Bentomne Slum U Other(explain under 7gl
MNIontlonrra ❑Re.o}rn
Injection Well:
7f.For rach material wlecttd aln/tt,pro%idc amount of materials used:
❑Aquckr Recharge ❑Groundwater keniedi:nton
❑Aquifer Storage and Reco}en ❑salirtin Hamer
Bentonite. :501b ,Wtr:ga:-.
❑Aquifer Test ❑Slamnt ater Drainage -- -
❑Expenincntal Techuoiog} ❑Subside-tree Couttol 7g.Prmide:a brief dc.cripticm,tl the ahandonment p"weilure:
❑Geothermal Wloscd Loop) L7Tracer
Once water sample collected, pulled DPT tooling and
OGeotbemral(Heiti 'CoolinttR��tumi l lOtber( sin under �T ) - -
backfilled borehole w/ hydrated bentonite chips
1.Date wrllt s 1 ahandn ned: 07/18/2 02 4
ia.Well location:
Motiva Cost Center #100370 AM t
r:xtlt(>Chi tt;t N nx Kwiln>mw of a lxablc) IL CcttifkadMt:
101 W. Woodlawn Rd. Charlotte NC 26217 '� 7/18/2024
flu steal Addre�%.Ctt..slid Zip SyhMt•:^«.:r'=� ?<:>: �tkr DMt
MECKLENBURG 16903203 11�•stll(aung dies)vw, 1 herehv eerily A&the well(s) was(were)ahartrkutcd in
tout. Pared Idenhfecatw,n No cPIN, dctxinku -e widr l,iA V(.4C O:C.(1100 or 2C 0-YV ff Wl C onAmchun Stanikinlr
and that a dnpy of this Pmw+d hm been provided to the well owner.
Sb.Latitude and knnxitude in tk-vvcsrmitwtc%1w. ands or decimal dcXry :
(if well fekl.one lattnttg it w1Tu toi t 9.Site diagram or addititnal wtAl dMMails:
You ma. trsc the back of this page to pwN de additional well site details or well
N V4' abandountem details You mas also attach additional pages if necessan
CONSTRUE-nON DETAILS OF WELL(S)BRING ABANDONED SURNI TTAL[NSTRUCT[ONS
.tthuA well Lv)avrucjmw mlr,nk.,,{7 atwl Ak. 14v-muhlrle n,rrctxln cr rw,n-e.,;, -,pp,
wtelhO LY%j1A the aamw uAmIrtr afm fd,arkkwment.toed Cart sa hm1 Wee k,rltt. Ina. For .All W'c16: Submit ties [cunt uvhm t) dr)s of ontpletron of uYll
6a.Wei IDd:RCD-12 ftoid000tcia In the fn4lowing
Division of Water Resource~.Information Processing Ueite
6b.Thal wtei depth: 35 (ft.) L6 P Mail Senice(•enter,Raleigh,NC 27699-1617
tub. Fnr lnlcetion % 06. In addition to sending the form to the address in Ina
6e.Bo►rbole diameter;2.2511 (ia.) alw,.c. also submit one cLV% of dus font%whin 10 dams of completion of uell
:daandountew to the follow ntg
Ditision of Water Resources,Underground Injection Conind Program,
add.Water k-tel helnw vound.urfacc: (ft.) t636 Mail Service(-enter,Raleigh,N('276"-I")
6e.Outer casing kaeth if laow nl:
31 (ft.) Inc. For Water Sunnh d Iniection Weis: in addition to sending the fort to
! the address(es) above. also submit one copy of (his form within 10 daps of
completion al•wcil abandonment to The county licabh department of the coumv
u herd ah:uxlrnk-d
6f.Gmcr caAm--lubmu t ngth(if lno%W:
hg.Screen length(if Lnow tic 4 (hl
Form GW-it, Nonh Catolttn Detstrinviv of Em wonntew aid Natural Resolmes-Div wan of Water Resources Rc.tsed Attgetst 21)13