Mecklenburg_Well Abandonment_20241014 (6)

WELL ABANDONMENT RECORD Fai Mum)Uq;ONLY:.
This•form can be used for single-or mulliple)Fells
I,Well Contractor Information, WELL ABANDONMENT DrTAILa
Robert Miller %L Number orvi'fisbdq abandoned.11
�Yc]l'Corlr�erorNanic{arurllow piMGM llyatsaminntnesuil.onNVII1 rvrapcny) For twglople ttfertlar Au rmN-uYlrc� fsieN* wells ONLY with d.w. .srarie
' enra47rrcfli�'mborP<lruirrae�r�ttrnciursaluiNl'alrl6rnt,
2675-A "II
7b.
r•IC IQ]ComradorQrlIftc;iiioii Nuirber Approximate vnWine of tsat�rc IiwiuinR in ircll(s): (Ftd)
• f
SAEDACCO FOR WATFRSEIPPLYMCIASONLY.
Conrpan)Name 7e.Type of disinfectant used:
2.%VettCousttvctiotipermitH:70001218,
Lrgt V11 apduwble Well per dh(Le!C,wrar,SlrrA,Variale•e.hy'erhar;,etc.)Y k-wwr! 7d Atnonnt Of d15lI1fCCt WL lt3eil:
3:Wtdl use-(ebecic.h•ell aw):
Water Supply Well: 7a Scaling matcaials:used(cheers alltiritc apply): :
prlgdcniturafl pallP EIKMici 1 KC, N Neat Cement Grout ❑Acmonitc Chips or Mlcts
00cotheromt(HcatinglCooling Supply) QRcsidontial Water Supp$'(single) . ❑Sand Cement Grout ❑.Dry Cl ry
❑LndusoiallComatcrcial ❑Residential Watcr Supply.(shurod)- ❑Concrete Grout ❑DriI1 Cultinp
i7lrri ulna ❑Specialty Grout ❑Gravel
NonAvater Supple Nell: ❑Bentouite Slurry I• 0 Otber(explain under 7g)
❑Manhoring ❑Recovery
Injection Well: 7f.For each atatot inl selected abos;e;liio�ide irntonri f af.rit;itesials tesetl:
❑AquiferRccba%gc OGrutriidwater.RetttedWon Neat Cem.:941b ,Wtr:7gal., Sand Cem.:lb ,Wtr:gal.
L1Aquifer Stonige and Rectn'ery ❑Salinity Ranier
❑Aquifer Test ❑Stonnwater.Draitiagw i
❑Experimental Technology []Subsidetrce Cotntu1 7;.Pi v ide a brief ocription of the altaudonmcnt procedure:
❑Geothermal(Closed Loop) ❑Tracer
" Tremie grouted with portlan3.cement from the bottom.to
Dcvothemtal(He:i(iart'Coolin Retum) 990ther(at lain under T )
ground surface,.,
d.natenell(s).abandoned: 9/23/24
;a.Well lucatron:
Pine.Island Country Club:
Fao)liq•lOencr Nmuc Facility IDN(K appliwbic) 8:Certiltcatimt: O r ! �024
;: ?-r g 3Q/2024
170t Stoneyridge Dr. Charlotte, NC 28214 -` -y /
Pit}sical Address.Cin:aid Zip
Mecklenburg 03139101 By s7gning 111LYPriv:7 herrby certify-that the rrell(s)tras nwm}abandoned in
Couaty ParcellilcWfikiOnNo.(PIN) occorrlanceivith"1i,i,-:CICO2C.0100.ur2c.o2dorGellCuras7rtrctionStrmtkmis
and trim a cnpybfliris record has been pn-mifed to'dre well corner.
SK,I ltitu�c and longitudts in dc�rtseslmfttutePisccnnds ar decinrafdcstrccs:"." i.
(tr,�cncaul,orstathongr5#tii0ckr ) 7.Site diagram oradditionalttelldetaUs:
You uta}•tse,the"back of this.page to'.provid6 additional hell site details or well
N `V. abaudormtent-derails..You ruay also attadi additionatpages if necess:m•..
CONCTRIICTION DFTA1115 OF WELL(S)BFINr.ABANnONED SURAfIITAT.INSTRUCTIONS b'
Arrade u!ell eorxruaefrurt nword(s)ifavwhibr
ls Fur hralaple iltjectian'ar rmn•ntitti7 supjtly
oriONLY WN1r A,svrngamrsnvraoro4Lhairrlarnreru,ton can tlrbml!wre funrc Ipa; Nor All Wettc: Submit thbi£ortuAvithin 30 days of cotuplctian of urlt
Ga.%Veil 1D#•AS-14R abandonment to the folloiring,
Dijisiu'n of Water Rtsourcii Informatiaa Proems-dug Unit,
6b.Total ivell depth:
5.i8 (O.) 1617 Atail Sciticc Center,�R:ileigh,XC 27699-1.617
101j.bor Tnlectian Wells: In addition to-sending the fort to the address In IN
6c.Borehole diameter:2 (iu.} abow.also Subunit one copy of this form;i6thin 30 days of completion.of well
ab:iudoantcat to the£ollo.whig_ 1'
lid Water`tevd heron Dhdslon of Water Resources,Under round Injection Control Prdgratu,
ground surface: (ft•) 1636 Arail Scnicc Ccntcr,Raleigh,KC 27699-1636
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Ir I
'6c.Outer casing lcn%h(if known): ( .) loc.Far Witter:Surinh IS Tnfectlou♦&11-1 In addition to seadiag the form to
the address(es) abode, also submit one copy of this fort within 30 days pf
completion_of%tell abandonment to the asuiay health depatuncitd of the county
Gf.Inner casiut jtubin;;tt:n)nh(if Imuvvn): (ft)
tvhctc abandonedd,
ft Screen length(if Iron n): 010
Faint G%11-30 Nonh camum Depanimm arEn iroonunt mid N:aurat Resomues-6I%1dast oC%atcrRoom=s Revised Aqua 2013
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