Mecklenburg_Well Abandonment_20230828 (15)

YELL ABANDONMENT RECORD Foihiternniti9eOlYLY;
This form canoe used for singte;or nuthipte Wells
1.WeH'eantractar Iufotmation: WELL ABANI l 11JR
Scott Hunt, Jr 7a.Nuniber6fIrt skein ahaudpnivl: 1
�Vq'eoli meioiMa ,(gr40 owner pcisoliall aLaftl"-uoll.611 LL9JIteP a ''Fk fiu unrtUple" JJij&doji or rwiiaF ater slrpPfy rti:lhs- ONLY Wth ,11re aswiit
9 e l :tx eoracrrrrdrtirum6anirlirrir�rrf,araN imP.+7ilr?rlowl Vol,fi
4561-A
Nt:`•1Wo11'ConitagorGaitiftcadoir.Nninbci
7b.aplibb—dwte volume ufatut rrinuinink iir`tvell(s);z (guL)
SAEDACCO FOR WATER SUPPLY WELLS ONLY::
Can>pany.Name'
7e.Up.rtif tlisi(ifcctant u3edi
2;Well C6nittucfonPeradt#:50000087, ,
11v m?ypl111ia1b1e.u�1P p<rinitr p'.e.CuLnh,SPeYa•,f"arftirxic,Irrctinrr,rfcl Pf,4tirrrcre' "
7d._t<i da.it of.'41fiCktunt ukd:
3.Well use(check iv&we)%
�Yater Supply WetL.. 7e.Si sling matetials!und(chceh'all that apply):
pArarf idtr►ral. phltuiil ilittllPttliiig. M NcatCemcnt.Grout 17 8ctttonftc-Chfpsorpcllcts'
❑tProtltc�r�t(Llcatipn,JC.00liri $dpnly} 13Wdcnd;i1 tV tEcr:StPp>t1)'(sinfilc) ❑Satei:Ccutent Grout ❑Dry Clap
❑Int[uslrtaUComntcecial t7Residerti.-11 Water S5rpR1) (thaaiixt)' 17 concrete Grout••" D Drill CiWio�s.
Olrri tioit: ❑.Specialty'Gruut ❑:Graivel
Non to u 0 0 Y...Wc11: ®BeMottife 516tiy 13 Other<vNplaiitutider 7$)
❑kiotatouin ' QARccotrri
Injcetipq WCII: - 7f For each tuatcrial selccted-abo��p6mide amount fiiatterfals used:
�Ai(trileclrecllrtge �GiquipitcfleiRCmcdlafiRn Neat Cem.:47lb .,Wtr:3gai•.. Sand Cem..:lb ,Wtr:gal. .
❑Aquifer,StorogeaWAkecovety 17S:ilinitpDander
❑rtiquifertest. ❑SlonwatcrDrainage ;
17E reritaeiusl Uchnotogc DSrdtsiderme Cotttmi 7g;Pril)ft u hrk-f dekripunn of;cfic'ul(addnnmrnt ptriecdusei
OGeotheanat(Closed Loop) CI'ocer
trimie grouted bottom to surface
Mvotherwd(lianfnMolfn Retum) ®Other(ai lainunder-? ) . .
4.pate well 0,abandoncd; 7-17-23 • ��
5&We location: 2023
Motiva f4 i
r3cilitfi/OrvrtorNaurna [acilitrlD�CEapplicabldj _ MW300 -
6851 Freedom Dr. Charlotte, NC 28214 5C5&& 1GCI't ' 7/28/2023
Physical-Addres.City,and Zip' siycirllM orc6tiGed Welt Cqutrtc or'1Vc11 Oirner. liiiio
Mecklenburg. I3y;,rP�nilriS this favir, 1 Iteri O C',tifyth.1 tlre,trell,0 tax(here!m6idaned irz
Camay Farrel W raillgtinn No.(Paej abobnfance;with I i t AIC.4c 02C,0100 or2C.0 00 IMel[Consinirtior Stearjdanfs-
• iutil that a'rnpt�oJdfri�rscurxl ktrs bE�'era pmvidcd to llrs:treN utvJier. '
Sb,I.ldtude snit lon9itudc in d�t�ecsrur€ttzttes/sceonrls or dcaPilal.degices:
(tf.�ticli C0.td,ollc UtritolJg u.irillctir�) 9f.Sib;di•:tgt�.litt or additional wcll defiffs:
You;iuity��e tli'e bade of Ibis p ge to:pt6yide additional A%ti-H site details.ar.imil
N t{' ..ab;irtitbuiltetit;deWts: You ruay aUb!:auaclt udditituid pd Vs, nei anl-
CdNS'CRtrCnON-DEtAILi OF WELUS►BEING ABANDONED "c,[1BbtTITAL LNMUr PLONK
,IPLettr n�ell:exrditrttrtririrJ'srtprdf3 if gviitlaPifr_..l�iy'mnlllplc rifj.�crlen 7irrwn•nvtir 13 j
11Y11d UNLY 11'lfh llxl'SVlIIN-C10175?/bK'f1U1N'f�iLk'4urnrcnrJ._r+�u can�rGmii wr�,,e,riri• l0;ti.Rnr.All Wclti: SubnW IIti:K:{f n iiithin 30.O s:of cattipletion of bell
sP-13 abandritimcrit lathe folloti��riG:
6a.Well IDfi•.
Divi don of�Yutc"r'Resityrc�;:LnfucnlntioQ Proces�iny;�nlr;
f�1711tril Sviee Ccatcr,R:ticieti,NC 27d39-t6i7'
66.'[htul tsell dptlt: 25
tOb.J' r inlotiort WAS.'Ill-addiliod to seudiug Wforth to the address in (Oa
fiC,Borehole dt ttnctet:l Ou,) above'-alga subiltit one copy of this form ttiihfn 30 daps of corupteftoa of pvtl
abnndonnieni to tltc following:
6
Divisiott of'Wpter Rcsounets;irn'tlergrouud Injection Coutrvt Pirogram,
ftl.\Voter tiiv'cl'bctrin--ground stirfacc;,10 00 1636 tNtrit Sctticc Celftit&,Ralc bh,Nt 23699-l63&
lOa For WaLgt;:nnly.&tnircttitn 114 rn'adililion-to'sending the foml to
6c Outer caiang tea k-(if kantvib): (ft.) the.address(es) above.-also,svbn11!1 bite copj• of ihis'than-tvittifn 30 day .of
completion;oF icelt ahandnunient m�tti-6unty hofth deptritntent_of the county
tvlicm ibat doncd,
" fif.inner cusinWtuli(nq C�yah Q'tf tnrati•u): .(ft)
6d.Suti�ca IengUt(ff ImotF n): (ft:) '
I }
Fonn M1,10 Nonh Carotlm Dcparutrcm of Endrunm et and N.•nural.Rcsoummcs-Division of Water kesowces Rcv&gd'August 2013
ti •
I

i
WELL ABANDONMENT RECORD rorlitteriatittseONM
This farm eats be used fbr single or multiple wells'
1.Wcll'Cantractor btformadou: WELL ABANDONNIENTDRTAILS
Scott Hunt, Jr. 7a.Number d1wils bcinRah3ndonwls 1
tiVeft:CouiradorNatnc(or�i llo�tirsipcc�ot�allvul>anitor�rr8aetl.ontii�tlferpippcny} Fbr Jriulitple- i1jI&ttwi .or t iz itfer strpph• 'Welts ONLY wilts .11r savie
. . - . . co mholiYlrtirtu�RtG)pN rICBr.w ill riv{afrirat,
4561-A 6on:Nnir>ber ((
TU.Approrcimsitc vgWmc of viattr iemaiitiug iInIvel1(s};
NC lYell'Conlragori'citiSca . - .
SAEDACCO Folt WAT.FRS.pppLY�vrLLL. ONLY.-.
Gampany Natne' �.
"rc,T3pr of dislgfivtunt used:
2.WdiCmtstructio-nPerEnittl:50000087, ,
Lit[d"Q'rp11ivbJa:u-ellwittiar.p'.e_Ceunh;swji�•l'Lirf&ee',rk'e tinrt•etctgJktntwtr
=. 7d:e�itiountof�liiJnfei-tttnt used:.
3. VCR Use(ehc&c'tt'df nse):
Wateesu 1ply WetL• %d'Scdling mutcrials used(chcd all'that aliply).
i7Ai;resid[nral. Ohturiisipal(PttbiiG ' !1I�Nt�t Cemcat.Gtinit 17 t3etuonitc ChipsorPcllc(s:
OCtcothcgn�l(HcatitigJCaOlitfa SupplS} Oltcs dcntitil%Vater.Strpp>}(single) El Sand anent Gmut 13 Dry Coy
Otndu5tri tU omincrcial p[tesitle t Witter$t�pP>y'(shairil) 0 Cbnotetc Grout; ❑DdII.Citiflu
Otrii boil O:Speeiilty.Grout O Gravel
Ntter-WatcPSuEtply�Vctt:. ❑Bentoaife!;htt'ip Cl Otber(6plaiatni&r7,g)
�h4ani[orir>;e. fl9Reco�rt} .
Lujcction iVclt: 7f Ea eacli matethal sciccted ahoFr;provide:ntnountef,titttcriatstased:
DAiluifCrlredrarpTe OGiquudwalerRetnedlatipn' Neat Cem.:471b ,Wtr:3gal. Sand Cem..:lb ,Wtr:gal. .
OAgtt&r Stoiugc.attil.Recovety OSulimq,Harder
OAttmfer.Test OSiomntttler Dta(uiige
pE.gtt:rinteittal Techuotog_t• bsubsidetce Contml 7g:Priljide a Itridd&m-t an of'thc'alrieslr nmentV".!c llui "
OGewhennal(Closed Loop) ElTracer
trimie grouted bottom to surface
OGeoilwFinallNettiRWCootin Return}. 1301her.4 liittuoder? }
�,patewCll(3}:ab ndonc�l: 7-17-23 L
Sa.We'll tpcniton: AUU2 S 2023
Motiva S:Cenillr�duu; Irlfirfl 2i:%�i1?c,cyr�;!�l,`s
racilitpi014ncr Norris racitity IDs(ifappticablclDWQISOG
6851 Freedom Dr. Charlotte, NC 26214 c�C.b GCN. 7/28/2023
PhgsicalAddrrm..Citv,andZip 5iu�cilrtaCcrrCanll9edWellCotur,setae We9lmirtxr- Di10
Mecklenburg ITyt�ISitLcg dies•fbrm,,f hemhp.certifj)-•1#W the uvllp: 14'aS ficere}.ahcmNated ere
Cottuty Psrcc1 lJcntitFe:itlouNo;.(PQJJ: nceitnlrnuxlpitti!;;(A'C�1C.0:''C:t11fNJ ar-�C.U?00 lf'c1f Gott�•![•ttcligti Stttniliarrls
imd'drt a.-c ofilv*t'scvrdhdsb'Ce?rpmvidi to7lre welt ouner.
Sb.iAOtudc and longitude in degrieea7minutr:,slsc6nds or do 1ual•.dcgrcc:g
(if..Yrtt Cri;td;orte L•ttlliing'is siitltescty} 9:Site di:igrzlm or addltional�cll dca.•tii�:
You.ivay ttse tl a h"ar'k of dlis page.id pio�iide addifiont l dell site&ails oi.itell
1! iV :ib;tuifoitntetii de'Wls'You tub•uts ailacit additioiiat gag es i.f ttcc.issat3�_.
tdNSTRI1C'iT1ON DETAILS OF W LL(5b BEING A®ANII(DNED "SLTflhft7'i AL,1N5`FRt7CTi1l�I5
.11taih".0--enzilmefigmircvnitsl if draollalilG:•Fvr MIOP!c bvit:lun ut•rrsrt.uxttir s rppfr
n,e119.ONLY mith itbandFor All
�ta fiIOonAl6 Submit'11> :.fsm iith ). . ttilGion of sirl
nnittohe6 ,Well g . allwinG- ditiyion of�VutcrR�agrC�s;:[ufatmitiuti Prna�xiay;YJnt;
2 5 IM 7 Mail Setvice eept'er•,I�alc'r�ti;I+iC i*9-1617
tgh.Th fnlection Wells: In-edditioa to Sending the fomi to the address(ti 10a .
shore,'-alto subiitil one cdpv 6f-this fora►iriidtiii 30 days of con�p[,=tion.bf well
fic,:Rpmltolc diametee 1 (iu.} abauilonment to the fallosvin
Itivis(ou of WaierResdtttees,3.Utidcigr'tiund hijetx[on ConctiA P.wgrum.
6d.\Vatee tcvct hctaa?gmaitd cusfacee,10 (ft) 1G3G Mail Servicernter;R71ci;,h,hC 27699-IG3G
i
fic:outescas9n len if lmown• Roe,inr Watrr:Gmn(v&'LniecHiin Welly; in'addition•to senditg the fomt to '
' )'. (fc) the.address(es) above. also subsist bne•copy of this'tams tyitliiit 30 days.of.
eomptction of ivctl abandai mint tP site county health-t$partnretrt of the county
svticr>r a�:iridancd. . ;
6i,[nnrs caltitil ftnliingFtmyFh(tf 6no�r•n)h (ft) � ,
6g.S►reen lent i t(if Imotin):
Fotm GtV-O 14onb Camlim Dcpantnem of Envirounicnt avd NatuM1,Rcsouxc5-akisiosr of VoaterA I oulcics Rev&O August 2013