Mecklenburg_Well Abandonment_20241014 (14)

WELL ABANDONMENT RECORD FatlntarmlUscONLY;
This fohn can be used for singly or ruJi liiple iitHs
1.Well Contractor Information: WRLL ABANbO1VMFNT DETAtl S!
Robert Miller 7st.Number ofAvells being,abandoned: 1
welt eompa-of Nanie(of%wil6%vuer NMGMHYamnauniriouall.anhivkrpfoperty) For nJrrlople fJfocNorr or •wn-unrcrl rpFfv wells OYLY yrrL .Me .smie
(0114(TlfCpiNJ•'a!'OIhhN(NJeiJr,Ivan crar,eJluJilr-wlc�rnr.
2675-A
dame of trutu rc d
NC 1Vcn Coalntdor Ceti ifimdoti Nnhrbcr
7h.Appmnbnate tri I ing in trell(x}; ( i►t,)
SASDACCO FOR WATER SUPPLY WE.[,LS ONLY:
Conte t>1yNamc 7e.Type of disinfeetant used:
2.`Vel[Constructian Permit fl:70001218,
L.W RJR applleable u•e11 parmity(i.e-GwnA-,Smk, e1011"kiowo 7d AIriO[m[Uf tllilnfectimt used:
3.Well use(checicttell use);
Water Supply Well: .7a.Scaling m;itetigdsused(check all tH:lt appir.): .
❑Agricn(turat ❑Mrinicip rublic N Ncat Ccnicut Grout Q Bentonitc Chips orPcllcts
❑Chcothcrmat McaciuglC.00lino Supply) ❑Residential%Vatcr Suppl}•(single) . ❑SMCIPC maul Grout ❑Dry•Clay
❑btdustriaUCmm�hcrcial ❑Rcsideatial%Vatcr Supply(sharer!) ❑.Concrete Grant ❑Drill Cultittgs
❑Itti tiou• ❑Sper-•ialty Grout ❑Gr.tvel
Rou-Watcr Supply Well: ❑Bentonite Slurry I ❑Other(explain under 7g)
Monitoring ❑Recocety
Iujcction We It: 7f,For each material selected above,provide amount df•umtetials used:
❑AgoiferRechw& ❑GtuundwilerRentediAian Neat Cem.:941b. ,Wtr:7gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Stouige and Recovcg OSalinity Dallier
❑Aquifer Test ❑Stoinn«r[er Drainage
❑Eytetintetual T ltuotogy ❑Subsidence Cotrtrol 7r.Pro3{de a brief description of tim abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Tremie grouted with portland cement from the bottom to
Meothehual(Heatn ffiolin Return) ❑Other(e� lain under 7 ) . .
ground surface.' t`p •-
d.Dateivell(s)abandoned: 9/23/24 `I1r„ Fl
Na.Well ideation: ! 2024
Pine,Island Country Club 1Gs.; ` ;: ? .-• -.,•,r .
Fad1i iC4 Nuhnc Facility 1Ds ifu Iiwblc) 8.CcrtlRcatau: 4 �'
hqvmr t DP ty rc•';.;;'�i���
1701 Stoneyridge.Dr. Charlotte, NC 28214 /j�� 9/30/2024
Physical AdJlres,City:ahtd Zip Siutgh. a :t,::.^."t;::,;s::ttt `'ti*n•ri r Uarc
Mecklenburg 03139101 By signing this farpi;I hemby terrify dial the irell(s)was(tene)abandoned ire
Coudl?' Pa-*1 ldnuifkn t nu No!(PINj acturdance trilh I34 tiCAd 02C,010Q.nr 2C.0200 rCell Co;w1hrclion Stawkieds
and!frill a aopyGflltfs record Ink been provided to lire trell owner.
Sh,I allude and longittide in etegiseslmtnuteslsccJtnds oril"cim:d degrees:
(ifdcil ra�td,orx kttifosig ii anffiticri) 9.Site diagram or adddonal Fell details:
You nta}use
the bat):of this page to proti'ide.additional atilt site details or well
N 1V. .abuudaiortetudeCalis..You ma)aLw wtacli uddidoiW pages if itfcZ3.9aty-
CONSTRIt(_'9'ION-DI:TAIH,S ON Wi:LUS)BFIN(:ABANnonn SUBMrlrrAT,MRTRUMONS
:litruh dell cvrvrruc4lalrr rrctanl(sl!J'atix1lreGla. Fur uaulople iujeaylaaa an'rwJrt•d•olar suFryJlj ' '�
arils ONLY verh the snmerWL%1rureknr'0 can submit cure funtr_ 10a.Far All %Veit%: Subunit this fottit within 30 dag of eotripietion of}tell
Ga.Well m#:MN-20R
abandonmcnt to the following.-
Dtviildn of Water Resourtin;,Information Prowaing Unit,
Gb.Torah tcell depth: 22.0.6 {ft.) 1617 Mdl S&%ice Center,Raleigh,NC 27699-1617
lob.Tor Inlectiort Wells: In addition to sending t e form io the address tu.10a
Cie.Elot�lydlo dlattteter:2 (iw) 'above.also kidnit one copy of this fohn i�'ittin 30 days of completion of v%vtl
abitndomnetn to the folla.%ing:
I,
6d,Water levcl.belon• band surface- Divislott of Water Resources,Undcr�tpund Lijectlon Control Program,
�. 1636 Ujil Scnicc Center',1lalcigh,NC 27699-1636
to
Gc Outer c sing length{if known)- ( ) lOc.Rnr 1Vater Sanniti•Sc fnlectinn Wells: In addition to-sending the fort
the.addresses)abate, also subruit bne copy of this form within 30 days of
completion of well abmdlrnutum to thcicoinuy health department of the county
Gf.Innercamtin)ftnbtny;[cn}Kb(if loturvn): (ft)
whcrr:altcrndoncd,
Gg.Screen leugilt(if hnottn):
Fain MI-30 Mali Carotlm Depsunrtn of Pnvironnhcnt mid N auml Rcso=cs-Division of Wntcr Resoa=s i Revised Araust 201-1
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