Mecklenburg_Well Abandonment_20230828 (13)

WELL ABANDONMENT RECORD FnTlat�rn,trvsVvN1�:
71its fbiin eati Ge usod for single or multiple iFells.
is Well'Coutnetor information: WELL ABANDnNM NT DETAILS
Scott Hunt, Jr 74.Number of ncils beiny,ubandoncd: 1
wm(icot ciorNatnc 4rualtour footle!! abaofonitr•�ueilonliisfiter u rtV Fa• .rrnrlople tiVI*Har or Millp5iYirer .aUnfAfv' K'a17s. ONLY �•lri) Ali •sane
Fu.Pe .) cbri3rnrcrtarrabairrtamrvra/,'jou derails alr i Ifarsb-
4561-A
7b.Appn)irltnsite tnlniitc oCS,fatcimainiu iu"ii�11(s}. (gui,)
NC1Vd1•GvmraaorCcitiSsatioit.Nmnbsi i � - .
SAEDACCO FOR WATER SUPPLY WELLS ONLY:.
Corripanp Nam
%Kip rrif duifilectant used:_
2:r/YL'IEConstructinnPerinit(1:50000087, ,
ldtr'off uplalla 5fr"urfl Jkrinitr.il'.a!Cawrary,Sdy,d'ririarn terra t;aiy rttl rf trruirn 7d:Amonn[of disinfidant used:
3.`Veit uk(cheek:hell use):
WAwl.Supply Well;:. . 7c.Soiling iMtecials Okd(chcci'all'drat opply)
grt�rrctirifutal. phititiicili tUF'ttbiic ®-Ncat Cenient.Grbut, t7 13cmonito Cgips prPclicts.
l34ic0.4lKri w oak n-ex.poutio Suppw riRcsidimiul%Vater,&Ippl (sinolo) ❑San&Qntent Grout 17 Di Cbv
C]Luinslrial((`otnn�cr�%il ❑itisicfr�di tl'�'V;ttcr supnt}'(sltaietl) P-Concte to Grou4. ❑DdU:Ciiuiugs:
[7frti foie - ❑Spedalty Grotto ❑Grivel
Non-N'atcr5u1ip1�,�Vett: dEeirtonite"51iet D Oder(esplaifijiuder7g)
❑ivfpititorate_ Mecotety
inj"don WCU: 7f For e��li materiitl sciccted:ahi►ic,pt oxide ant6untaf.en;thrlais nosed: .
OAquiferlfeCltuge ❑Gtpttixittalerlaeruidlatipn Neat Cem.:471b ,Wtr:3gal. Sand Cem.:lb ,Wtr:gal. .
OAgaitir S(ontse atd.RecoN•ew PS alinity Bottler
❑Aquifer Test ❑Stonn%W crDiatmige
❑E.yteriatental Tr cltttotogv'' OSuitsider�c,CotMml 7pr P�:itnid,`a ltruf:de eriptioa of ttic all tndrintn¢nt riti�Etifuiz:
06eotit unal(Closed Loop)
trimte grouted bottom to surface s;�
�Grothetroat(Ei tinRlCoolinj Return).. BOttxrdo� laic under 7 ) .. `LZVE
,i.patcttcll(s);abandoned. 7-17-23 AUG 2 S 2023
Sa.W.c1l,toea6n: IrlfOfi1;811`n Pr^c
Motives
Facilitrr�4'r4ncrN.utie. ra:ilily LDs.�fappilc:tbic) 8:Ccrtl(ir�tlun:
6651 Freedom Dr. Charlotte, NC 28214 c5�&& ;t 7/28/2023
Piivsieai'Addtcss:C�ty,a!id Zip $tez�inite ol'Ccrtined%Yell Corrtr:eCIo r Well oivmr Dw
Mecklenburg. lfjr si�ielrig this fnrfr; 1 leemby;eertif !!tilt Ike ue11(q)ties.(lre>z}alimidoreeJ ire
County PSreel.id::etifttloo No,(PIN)" u"",rzfrnce 1pilJi ls f md' 02C.0100.or 3C.4?00 Ti'r11 Colishwctioti Starriferds
cuiJ lhrir.a.'cQpy of 14T a sour tl.lrers beget provfmoJ o[ke iYell titiirer .
Sh.t;atitdde and lohgttudc in degrccalnti[iutcslscconds o r dcsimut;dcgt toss r
0fAvou swj ooc,.LAlki,tgis si nciepa) W Site dl r eni or'uddtticaoat galdgt itlsc
YOU0my tcse.the!lack of Wis page'to protide:additiotial Roll site d�lils:or.Well
N. . W. sib;itidotlinetit details: You Inak iiLsolI;attach asfditional pajos if ne'cisc ary-
CdNSTRII&l0L*4 DE,TAIIL-'S Oft Wi✓LL(SV BVINC..ABAND61V:D :S[IiIRtTITAL INSTRIIQ TiQ�IS?
.lrra_,*nrllci ait aclMrt mtwtl(sl-if avnllu d Bar trrnitiplr utjerr&m ut•lion-vertu mrpptjl {
u�1fa.O,VLY vIIA il.c 3vure•enusrtvrriore+aLiveehurrncnr.j:rrt"cart�rL,rcit iiwre fuare 10a>Yhr.All Welle: Submit iKs`fgtm iiithirl"3t)dtys.of co"k4ina bf'tir11
6a.�Vctl II)g•SP-17 lbandonnictit to the fpllouuinG; I.
DiAsion of Water Respur6s;:inftirnwtiuti Prow-ila;Unit;
2 5 1617 Afail.Sctvice.Gcntcr,Ralc`t�di,NC 27de39-1617
6U.Total trill dcptlr:, (l4:)
td1j.For inleelion W—dy. 104dditiba to sending oleo Pori to the addtzss ttt Ma
6c.Roecholo diameter.1 (ta.} abo of also subunit our copy of this Porn;Akin 30 days of con)pteiioa of will
pl ra domncni to tilefallotiitua;
fd.Water tot`ol bctott:gro tnd sold iec:,10 (t¢) �livislgtt of Water Resources,lTtidergrbuud- '_e lon Conttvl Program,
163G tlla.il Seri�cc('enter,Ralc'egtrt 1tC"Z;699-163G
6c Outer raisin length(if known): lOG Fnr 1Vater:Strnnly.Cs lnfel6a 3Velly; lin addi.ien•to wilding the fornl to
tine.address(es) above:also submit bile Copy of this•fomt Widiin 34 days.of
complction:of ivel-I"kandaiu�cot to tttc county hcidth depurt'nictd of the county
tFherC ai?arld0tied•
6f,inner crsin f[ulnaa tength(if larpvcn)i
6$.Smvn length(if IMOti'n):- 08.)
FormG1V-30" 'NanitCautlmDepona>cmOfEnciroouicntaod-Natwal.Resowces-aivislonofWatergc 0drCes W�i$n1 ugusi?ilt3
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