Mecklenburg_Well Abandonment_20230828 (16)

WELL ABANDONMENT RECORD
This fornn caii tie used foe:single or nittltipte wells
A.Neil"Contractor information: `VVLL ABANDONMENT DETAM9
Scott Hunt, Jr briny;abandinttd: 1 '
Nc3l;Co,r"LjorNamc,(oi5inllosvmr"]Ia Uyatnndo,dng�eell.osifiLalllcrprupeny) Fa nnrtgple. irltiruwe .or iwri=N¢atar "suliPA, KiJ+s'• AVLY w11h .tlx sails
MIS rrrr ilM4mSN$iO Mill :)mv iur wav,6I uleform,
4561-A
7b.Appr»ziuistteyrilnmc of st ittt,reinawlig in ridgs};.
NC��eU'CbnlragorCott(fiatdoq:Nnit�acr � M �
SAEDACCO FOR-WATF.R'.SFJPPi,V WELLS ONLV-..
Catt>party lrainc' 7e.Typrof4iA6ft_ctunt u_rcd:
2:Well Construction Permit#:50000087, ,
r
Ltse"tdlolrlGrubl�urlJlserreltt p'.cl Cwnrr,Sra ee.J'orr�mae.li rcLui etr'.t(fkimwu 7&.tiriotttitaf'disinfectantusttil:
3.%VCR uae(rettecicrr•&U.,e):
Water stiilply weth -74 Scali tg m;ite ials used(chvizic ilCihat 4pilly):
pAStictdtgral., pbltitiisilialll'ttbiic. DO-NcatQnlcnCGrbtrt p 8craonite-Chips orPellcts.
�Gcotltctmrit(H¢atitic,f Coplirio SaPPty)" .pltcsidttitilit�4'afcr SiipPly(single) •" ElSand.Centent Grout ❑Div Clay
t3huhjtria1/C0nmtcrgfjii ORWcknthtt Water SouRi}'(shnird) n ConcntcGniue' El Diffl.Cltuiug$
l7irii iau p.Specialty.Grout p-Grtrel
Ritn=\Vater Ballot)�Vcil: 0 Beidotute S1463 Cl(lther(explainAffider 7g)
ptrtanUarLte �9Ret:ar•en - �
injcctian Well: 7f:For eadi tuAtceial sciectcd aboi'e;pros•idc amottnt4tuaterials usi iF:
ClAgnifer'It. . Q�e pGttiuiidttrlerRemcdiafipu' Neat Cem.:471b.,Wtr:3gal1. , Sand Cem..:lb ,Wtr:gal. .
OAquifei.Sto6 a and-kic:ovr ty M. Ainity Wrier
l7Aquifer Test ❑Slonmc;tter Dinit uige
I]EVerintnrual Teclluoloer• OSubsidetce Coti tnl 7> Prjici brief- tpta nn: dr t ► mertrucJu re
Mothennat(Closed Loop) 13Tracer, '`
trimie -grouted bottom to;aurface
pC,eothenual tHeittin Caofina Return} ®O(her w lain under 7 )
!r+
4.Rate ss'cOW.abandoned: 7-17-23 AUf; 2022
Ss.Wen lucaiton., � �®
•Motive DWOj•N•RN.Lp oo 'a .Kl
facili lO'vticrNain rwility 101t cloppticablct S•CcrtiRcatign:
6851 Freedom Dr.'Charlotte, NC '28214 �L'9 /,L/!.L �/L 7/28/2023
Physical Address;Cii,•aW Zip signtttmorCenirlod Wen C'ntaatc� or.}Vell Ow or Dine
Mecklenburg I tt sr q:lrq 1A0 fr mi, Lhemby car7i�v<tfinr`I&tive11 fs}irac.(teen}ahmidaned hi
tnw=ti Pa,re3.t nt![$ea1)onNo:(t�[Nt' i►ixUnliincetri!!i'1 hC.IC:62C.0100:urZC.d200MeffConstnictiunSlnutkards'
lard,d ilrrit,a,cQpy e-i1dT record his bee+i pmvkkd core hell cjuner.,
ih.411tude and Ipugitude In degnees'IMIUUMAcconds or dcciiora1.degMm
(if.6'4tt fl!:idj'Ope�t�.ltll�Ilx l$.Sltlticxl>t) -4:Site diabratie ttr-addittanaiss'dl tictatls:
Ydu:iliac use t e hck of tl aiis page io,p ovide additional mil site details or.coil
N �� :—Idotultetu�1a0tiis:Yc ►n u ay also atta ch adrliiioti tt pagz's ifssa nee n_
CdNSTRUCfII1 X DETAILS OF WELLiS}6E1NG ABAND6N1EW "S�U13htiTTAi4 iNSTRUCT(O
Math n 1l:runitrarrtlun'iiewetsJ If avallarilr,.,far nenl4j#e tujretliut ar-,wr,•uxtt,r supp� i
wee ONLY 1rltJ, edu M&MY1.(MM fu?'M' of 19iq:,For All �Vrllc: .$u6mit Utrs'form siitttin,30.da}s. cattiplctiuit of sirlt
6a.Well[D&:SP-16
abandonment to the fptlawing'; i
Divisian of Water Rrsn�rcCs,:Infurmntiva;Prgccxaia(;Blttit;
24.3 5 16i 7 Dlril Scrvit c Cetitu,l2alcit;6,ltiC?ib9'1 II617
60.TOM isill•dCptlt: (tit)
1tOb.Div Tnleciion Wells: In-addit un to sendiug.tlt+e forut to the add.tess fit 10a
6c.Bbeclsolc diameter.l Gu,) :'abaut.�alsa snbiuit Otte copy of tuts farm iridgir 30 days of-wnyttction of well
abandottmeni to tficfallouing; 4
rd.Water lcr'cl bcton.gt oirtid surf iiece;10 (lx.) Iiivistott of wateritimur,ces,.IIndcrgrouud injw[on Couttiillririgram,
1636 Mail Schice Center,Raleitrh,tit:2 i'M9-1636
6e.0ateir raising Wnpth.(if.lmown): (fL) I(Ic For rVater•Sunn1�..C'inficetfiitn cltb; br additiap`ta SetlditlSt the.farm to
the.addfess*) Oote:'also subnrit`one copy of this'fbrut wittlin 30-days-of
completion of hell ahandoittneut totthc county hearth depatvncni.of the county
6f.Innereasin'Jtubib..tength(if hmown):
where lba idomd,
6g.Screen.lent llr(If lororin): (ft.)
Fdnn GlV-10 North Catollm D'gwnxw of Pnsironurent and N:nucit.RcsotmN-Di,islan of W_at.rAcrowV-s Rcti•isnt'Au�,si 2013

i
WELL ABANDONMENT RECORD Fai lritetiwl Usr O1VT Y
This form can be used for single or nndlipte cells"
1.Wclt'Coutractor informatiou: W`FLL A8ANDQNh1EN'i'DGTAtteS'
Scott Hunt, Jr 7a.Ntunlier6fn'Lql%beirig•abanilo Iei: 1
Neat;CorycaMortrauac(Ott'sallouwrpusmrallyaLgn ontneiiitl.onI&Itwrpralxhv) Ar re iftJO.e,I lij(eiylur or motmi-drel•, .�tgrptf, e,alls. ONLY with .thii -suite
rnnettrreluaareabulYlnms�RaG}Y)ra[YPr S;afuarit ruJaforba
4561-A I ;
NC 1Vc11 Gvnirlgor Ccitfffeatiou Nnnt6ci 71►.Apprpaciinatc I•niting of t*ater matainiug in�i'x11Qa}I. (did)
SASDACCO FOR WATFR.SUPPLYWELLSONLY
Company Namo W.Type'iif disitifietant r eed-
2:Well Catutiustilon Pcrintt g-50000087,
11vadl n1rIJ11ca�1r1�_well periariar o'.e.Cwrdry,Swi?,flarldwe.b eaioi4 w)(jkrm�rra
7d:Aitioutit of Wilfectiurt used:
3.Welt use(ehe&:WLlj U--.):
Water Supply Well: 7c.Sealingr m;iterials used(cbcrl:aifthat aj►ply):
DAZrtcnitoral. phtimicioVh,Iblic M'NcatCemcnt.15rutt t] 11c1►tonitcChipsorPcllcls.
l7 tlicnis,•tt(4catingJCootin3 Supply} 171esidcntWI Nafcr.Supply'Csin�ric) 17.5and Cxntenl Gtnut ❑"bry Clay
❑lndnsirbilflcimutcrCial ❑ItesicleruialWatcrSupply�(sharcd) 0 Concrete Grout ❑DOi Ciiuiups.
oirii' tioii 1.Spe iaily.Grout El.Gravrl
Non=WaterSupokyWctl: G BeidouiteSlutiy. C1 Otber(explain pbder7g)
Ot4iotlitor6ie, MRe:ovety
Injection Well: 7f.For each material setccied AboFe;pkAide antoont of.materials used:
17e1quifer`lYectnirga ❑G{ouiiditaterltemcdia)tian Neat Cem.:471b ,Wtr:3gal. Sand Cem.:lb ,Wtr:gal.
OAtlttifer Storage aix.Rctiot•cty OSalinity Wrricr
❑Aquifer`jest I9Stontnriter Drainage
OEN►erintental TechuotoLm ]75trtisidctice Contrul ?g:Feirsicfc a Ircuf di criptign,t7fthc abaeidnnmamtp n!FWur=
Cltaaothemxil(Closed Loop) ClTtacet trimie .grouted bottom to surface
13Ceotbernial(Heatin?JCootitiv Return) 0C1th r t�E lain uWer 7Rl .
d.Date nelt(s),abandoned, 7-17-23 Y t �
5a.Well tocalion -AUG S.r••R• ?
Motiva ve
ti.Cetlpirctien: ! In4`arcv 2aCtl Pt^(�raot'
rroiliytOisncrNaiiatra Fa0hy lD9 Cirapplimbld) Una•
r r
6851 Freedom Dr. Charlotte, NC 28214 �« 7/28/2023
�
Physical`Addres_City,aid Zip Siytihac(irCemillcdWeilCorac ararAVcVOii-mr. Diilc
Mecklenburg 13}+sl&nJlrir This fnrtrr, I Irem6�i ce1 tify:IGnr f/re ivAffs)irrrr.(ieerg/0undared in
louuly Parcelldcum.callaat No,(M)- aecortlance with 13;4 XC.1C 02C,0 100.o r X.620 0 Mel[Guraah7iclion Santkrefs
and llirrt a'c¢pj!oJ'11dx 1"e-Urd.44 c be"ear;provii ed ta!/re'is e11 gtraaer•.
t.I.ititude and loiigitude in 4ege teslku(mi cslseconds or dteinial-Acgrecs:
(ifpeD CVtd,oue tatitflngusiitlicic 4) 9.Site di;tgr tm araddltloual�cll del tits:
'You.tuay use'the bacl:of Otis N&to.provide additional«ell site details or.icell
1✓. W :ibtivaorinteiit�ie0iils:You Ways also;at1aA additional pubes if rlei issaiv_
CONSTRUMON DET-41"6V WELLiSt BEING ABAND6NED SUB14ilT1 Ai,pggTR[T�TIQVS:
Attar ucll cYrmttrarclbara ri�vdlai lj'dtiatlaGla. Fa+amrlfip7r iJJretlrirt iu rvri•uYthY strJ/j "
n 11a.ONLY vdth 11.10 saJJMtYauarrniYioxraL"mrtFurmrru._irau Carr3rrlmii'ru�fu»m ilia: For All W&J.'c: Subuth Ihls'form ttlthin.30 dkV-,of;coftipIction of%kil
6a.Wctl ID#:SP-12 abandor.inicat totbc follo yipig:
DiciAmi of Water Resep.ir,:aS,:infocmpHoa_ProeL�Lsing ITnit,
2 5 ifi t7lLril Smicc. cnti r,Ra1ci;;5.1tC 27 iCJh-1617-
6b.Total well.depth: (ir:)
iQU.gar Inlectlhln Wc11s: Ut addition to sending tlk fount to the addtess iu 10a
abovv%also-subinit ouc eupy of this torus ividiiii 30 diy8 of completion of%i-ell
is Borcltole diamcter:l abandomncid to the fallo«•ing: i
t
Dl islott.af WstcrRisonives,�Undergrouad iiije5ton Con(riit Prngritm.
fil.Water level hc[r .ground grrfaee:.10 00 1636 Alan Service 66,n(er,Ralcio,NC 23619-1636
I
6c (inter casing length(if lane rt): (fr.) IRc:For Warcr S►mnh t`C'inrccttnn'`Veils; In addition•to sending.the font/to
the.address(es) above.also subnlit one copy of this fonnt witiiia 30 days of
completion;of�tcll abaudannicut(o i6e county heatih•depa tmcnt•of the county
6f.Innercasin /obtaltbeigth(iflmmvn): (ft.)
whcm ibatidoncd.
6g.Screen ledgth(If kumstt): at.)
Farm G1 ,10 North Carolina Depontivoi of Environment ate Natural Resomes-Division of WaterRooiuns Revised Augusa 2013