Mecklenburg_Well Abandonment_ (17)

WELL ABANDONMENT RECORD For lnenel UW ONLY
This tram can he used for single or multiple wells
I.Well Cnntractnr Information: WFM ABANDONMENT DFTARS
Brian Ewing 7a.Nunibrr of wella brine abandoned: 1
N',nl nlaiYel01 NJi1\IUI M2If UM RY pCfSOIYBt almdaNa�C wCll Ull ha'ILf PrUpfn)1 Fv mWnpk .rile.hmr '4 cam-+<nrr vuplJr .4h; ONLY afd /hr raaw
r .'M tNN uhJMIrMNYXr I.rM tlN WhmlI rYK hm
4240-B
7h.Appmdmatr rnlunw of w atrr rrmaiofee h peWak 1841.1
NC Well convenor,Ceilificalion Hallakr
FOR WATER SUPPIA MF.IA SONLY:
SAEDACCO Inc
Coapoa,Name 7c.Tspe of dirnfecWm used:
L Well CamttanYhm Pervall N:70003075,
bard? Ti—A, +. .. —:' war. Vwe.I,vmmr I,nr,m,r, .a J1....r
'd. Amount of Jisinfirtanl used:
J.Well aar(chndt veil Vert:
WNer SUPPb Weil: 7e.Sealing material\uavl(chcek all that ApPI!,1:
❑Agrcoburd 0Manx;gML1h"x M Near(cement Grrnn Cl Derlondc Chips or Peliets
IXkcalicmeJ IHcmag I iudnnht Supph I ORcsdcmml Wmcr Siryph Isnngle) O Sand(Clar t Ganl ❑ On('la,
❑hdusm:ll:('ommerewl OResderstal Water Slrpph Isharodl O corktrir Gmul ❑ Doll Cultuip
AIM bo, ❑ Spocialn Grout ❑ Grind
Nan-Motor Wpph Well: O Bemmule Slum I (hlic te\pLnl.uliden 'gi
xl,lonunnuc ❑Rwo%en
Injrtlisn Well: 7f.For each niawrial selected abate_pmttdr aminmt mf malcio rind:
❑Agatcr RcLh,agc O(innond%ma Reniedlatiovl Neat Cem. :4711i ,Wtr:3gal. Sand Cem. :lb ,Wtr;gal.
OAgmfer Sa)ragr and Root m ❑Sahmn Damer
OAqulfer la ❑Slonlmakt Drainage
OEryennlenml Tahrobg2 ❑Subwcklcc Control
7L Pmi id<•a brut drseription of the abaVihrnlnwet pniarAtRz
OGeoltvmctl tclosed I.00pI ❑Tracer
OOwihential McounglCoofing Rehm) ❑0ther jc%pfalrourderi I treei from the bottom to surface
l Dele aix8(xl aMedtltltelk 11-1-22 - ..-.
e
VEP
5
.is.We86pVtllte:
Norfolk Southern Internodal Yard ln(Oflp i-" Pr-;,weo ;g Urn
Facdin'0avcr Nnmc Past,me afapplrcaht R.f rrtinratinn: DV 3rJG
iQ1
333 Parkwood Ave, Charlotte, NC 26206 Brian Ewing 11/11/2022
PM seal Addreu.Can.and Zip _awns of('am 11.d%a ramn.l I "A Oann Dow
Neeklenburq 08301126 /it tilinaW Met jirm. I herehi i r r,;i thaor like wells) was Meru abandoned in
("an, I'mul I&M4eAI,No 4PI%1 o(rardane with 15dVC4CO2 ',0100 or:Y'.021010 Well C'tmrim,I.....VamFrr/t
rmd that a e'tprt of Ibis record hat been prol-ided ro the cell,caner
Sh,lawitade and lanpttnde in dtVvrvmimnrn:,awade ar dermal degree:
If sell veld ne,Lot bop n.alrakvi 9.Site diagram or additional well 4k-tA41%:
N ou wrn ID('Ilk back of this page to pen de addraoual%ell ear details or sell
N _._ M abaldc arrcm details You ItIm alw:avail aklltalell pages if necessan
CONSTBUCYION DF IF LS OF ME I.I ai ail I N I, tB\S DON 1:1) SCBMITTAI.INSTRUCTION
.Itmafi
+rn.2N.) .riser N.o-- Ma. For .40 M'db: Subaul Ill. loan vittbm 10 lots of conipletou of "ell
ai M'rll ID,TMW'4 ahaidoamcm to the fohlotung
llh,Wom of W ater Resisters.Infaraunhiw Pmct'.ung I nit.
rib, Imlal nrll delnh: 15 It i 1617 Mail Scot lee(eager,Raleigh. ,( 2-IM-I617
lob. For Lnieclloe Well : III mltfltwa IU rld"w Ilk Iona to Ilk:ddkr cal IUa
Iin.i abu,e also sulontu our cup) of this form %nhlu to Jars of completion of%ell
In.Bur\'IMJe'd1111%'ICY:1
ab:uahmnanl it,Ilk IiJluw rile
Dhuinn nr Maler Resources,I.nJcrgnand Injection Cultural Pnmrain,
(,it.\1 Ater k'rd brinw ground wrfarc: dl.l 16J4i Mail Senior('enter.Raleigh.N( 2709-1636
Ilk. For Water Sunelr& Inurlion M'rlls: In addhao to carding the font to
I,Outer caring length lJ know no: Ift.) the :ddwsslvsl abuts also whom oak cop, of this form within III des of
coarpMmn at„ill aKi donircm Io the :aunt hcahh dcp:mnkm of the canton
„Ikrc.tMlidnlad
e/.Inert tasiny''tnbiag length ail'Mown): 5 Iltl
tot,Screen length(if Mow n c 10 111M
1 .,., r.:A-- NonhCamiro Dcprl ofEmlmmncead Nml iResoaacs - Dnulonof wave N.uwms Re.aeal Aipa-N)It