Mecklenburg_Well Abandonment_20230626 (6)

WELL ABANDONMENT RECORD For lnurnalUsoONLY:
This form can be used for single or mtilliple wells
I.,Well 611tractor Information: tYELL ABANDONMENT DETAILS
Scott Hunt, Jr 7a.Number ofnel6 being abandoled: 1
Wc1L'CotMranorNnntc(orucllo�sncrpc¢onatlyattr mdng�eillon}ugtLcrprapeny) Fa• Wifloph f/YeItiar tie r1,ri-confer srrpjdy aelb 0NLY bill) 11,E swje
cmtsfrrrcnarhrl,artlarnnr)f,yarr aar.sr)tm l r wtafornr,
4561-A
7b.Approximate volume of vvatw icmaining in wrilo)Q
NC Wc11 ConitactorCcrldiicalion Niodxi ( d)
SAEDACCO Inc FOR WATER.SUPPLY WELLS ONLY:
Csmpany Namc 7c,Type of disinfectant used:
2.Well Construction Permit tl:, ,
Lit di u11pherrb6r uxllprrnrftr p•.e.Cantu',S1111'e,11r,riwtu,h6ediall,ek.)flawwr) 7d Amount of disinfcrtant uuvl
3.Well use(ehe&well use):
Water Supply Welt; 7c,Scaling inaterirtls used(cbeCli all that apply),,
MAgricuitumI QMtuiicipaDT"uhlic M Ncat Ccrocnt Clot ❑ 13cntonitc Chips or Pellets
0(kothcrmal(Hcating/Cooling$uppty) ORcsidential W,itcr Suppb,(singic) ❑ Sand Cernent Gmut ❑ My Clay
❑BndustriallComnicicial ❑Rcsidentutl'WttcrSupply(slum:dd) ❑ConcrefeGmut ❑ Drill.Cuttin;s
17lrti 'lion ❑Specialty.Gtoul ❑Gravel.
Noa Water Supply Well: ❑Bentouite Slurry ❑Other(esplainunder 7g)
Mmonitorine ❑Recover
Injection Welt: X For each tuaterial selected"above,provide amount of.Materials used:
❑AgrriferRechaige ❑GroundivalcrReutedistion Neat Cem.:301b ,Wtr:2.Sgdl. Sand Cem.:lb ,Wtr:gal.
-13Aquifer Sfotuge alai Recoven• l7Salitdty Barrier
❑Aquifer Test ❑Slotnmatef Diainage
❑Eyrerintcnlal Technology ❑Subside»ce Control 7g.Provide a brief description of the abandnament promAurc:
Meotheuml(Closed Loop) Mracer
®GeolheRnat(He:nir )Codtin Return) ®Otherfex lain under 7R1
Us'
4•Date nell(s)abandoned: 6-1-232022
Sa.Well location:
Former Univar Site i
Iad7d)a'Oivni r Now Facility wx ofapplicablcl S.CeralIIcnlian:
5010 Hovis Rd. Charlotte, NC 28208 �CdC.[, 6/4/2023
Physical Adds,Cie♦,and Zip siSrrahtroorceilmod Well Cunt 'r or Well Owwr bile
Mecklenburg. Icy.vif rrh{g M&frnta, I hereby certify thvt the a ells)tray(trEN ahanriaued in
Chunky Patrel ldcndffiicaftt No.(PIN) a=rdlance W14!T.$XC fC OX.0100,or 2C.0200 lr'C1l Ctrnsintction Start[htrils
and drat a eopjr ofdlris record has been provikd to the well owner,
Sb.Latitude and tongitude in degmuslmfnuteslseconds or decimal degrees:
(ifivall GM,ouc MiAong is sitlrleieul) 9.Site diagram or additional well details:
You inky use the back of this page to prrn,ide additional well site details or well
It W abandonnteru details.'You tuay also attach additional pates if necesstn'.
CONSTRi1CMON DETAILS OF WELLiS)BEING ABANDONED SUBNtrrrAt.INSTRUCTiONS
trra4l t,rll raravrrndka mcwd(V y'av,ri6a k_-liar ftwhiplr.b1mcdqu or m,u•nnler supply ,
rrY11x ONLY 101h ova cnnsrihmfi arre ftntr. 10a..Fnr.All Wells Submit this form ivithiti 30 days of completion of nr11
6a.Well ID#:MW-7 abandonmcpt to the folltitying:
Dipisihn of Water Resourits,InformadonTroctsung Unit,
6U.Total well depth: 24 (rt,) 161711fail Service Center,Raleigh,NC 27699-1617
10b.Fnr Nolan Wells: In addition to seodiug die fora)to the address in 10a
fie.Borehole diameter 0.75 above,,also submit one ropy of This form witlliu 30 days of cmmpletion of well
(in.) abandonnicrn to the follnti•ing:
fed Water level hctncr 12 Division of Water Resources,underground Lijectton Control Program,
ground surface: (ft.) 1636 Mail Service(:enter•,Raleigh,NC 27699-1636
6e Outer casing length(if lmt►w n): (ft.) 10c,Fn[Mim-5unnl,A Tulcctlon Wells; In addition-to sending the form to
the addresses) above. also submit one Copp of this form within 30 days of
comptetion of well abandonment fo the county health department of the county
Gf.dune)ctsing/tnbing length(if[arovrn)h (ft.)
whcro abandoned,
it
6g,Screen length(if ltnonn):
I
I
Form GW-30 Nonh CaroUrn Depanmcnt of Fnvironnrcnt and Natural Resow-ces-Division of Water Roo,uces Revised August 2013