Mecklenburg_Well Abandonment_20230828 (17)

WELL ABANDONMENT RECORD FailtalcrlmdUscONLY: j
This foitn'canlie used for single or multiple txclls-
11,Wcil'Cantt•accur information: WELL ABANDONMENT DL1°A S
Scott aunt, Jr 7:t.Nutnherofie elk beidytabandoned: i
�Ye3t;Cuulracfort3aurc(or+c]Lo�vn�j gor�allkal�andmdv;++:ll.ontiiisiUryrp-lie yl cu rrrnlftple- "B�ictfwr .or, iwrr-rs4iter .supFvl srolis- GAYLY utfli .N.r swift
€anarrtrcfiar4ayiurdrNrrri+Fjat;)nn cyor submit iNrd fnrni,
4561-A
Nit*01'ConlraaorOcitificaliou.Nnu+cr ?ll.Apiirnzlwete�nlnincuCsrat�Y ftetttaiminBin"it'dl(s};. " ( id.l
SAEDACCO FOR WATi~"R SUPPiX WELLS t?NLY.
ConVany Nam %Tvpe of tlisinfertant used:
2:Wel[Cdastructian Permit d:50000087,
Ltsffr11n1rNllcuLl�-urlfrfrrltyp.LCcunh,St�t�.lnr4irm.fir,�rctfprr,.krl ?d z�inountu['t115infciAuntusCd
3.Well usie(eheelc'tt'ell Ust):
Water Supply Wells 7c.Sealing iioatco►als used(eheckAl[that apply);
C7dgricirifamt. QhltmWiNvpublk;' DO NeatCemcut.Crout f3-Semonito.ChipsorPclicts
❑tacothcrural(Hcafiiir�'t pgliti Supply) ❑Rcsickrttilrl W:rtcr.St►pp>j'(single) ❑-Sand Cement Grout 13 Dry'Cl;ry
�Hra[tislri;r[!t cimntcrCial l]Resiclentill Water�ltppl}(stutiirat}' r►ConctFtc Grout; ❑ Drill.Citttinps
O @ii-`bait a Specialty.Grout I ❑_Gravel .
Ntiu Water 5uttp[y.�VcB: Cl-entonim Siitrw CI Other(explain uoder 7g)
❑hianttarLrs 1L9Rccover
Injection Well: 7G For cae6 tuaterial selected aW'e; provide'amount of rttateriais used: -
[]elquiferlrcchrrge 17GiouiidgalerRernettitttipn Neat Cem.:471b ,Wtr:3gal:_ Sand Cem.:lb ,Wtr:gal. .
DAquifer 5toiagc and Recpvcty OSolir►ity Darticr + '• .
l7AgniferTest 'Li�Slotrtnt^►fer Dtaiu rgc
Subsite� ar 7F P in ahuidnnmcntpivccdure-
LiE.�erineival Tic ahredc erie
Mcothennal(Csed Loop) OTtacer
trimmie.grouted bottom to surface
DGeothensal.(HcntinW2olitteReturn) ®Otherf�lainuhder7 ) — ,
VED
6.Watett'eU(a}:abandoned: 7-17-23 AUG 7M'
Ss.Well tocation:
In.�';rxv^afirn �,� a(.RBI
Motiva DW
FacilittrUsvr>crNattro. rociiity.twi-cn pl-+c*W R:Cerliftrnlion: 1
6851 Freedom Dr. Charlotte, NC 28214 �� 7/28/2023
Physical'Addtcm.,City,and Zip si-amlace orCcniriM Well coltIMO&Welt Oi+•t>;r Dwo
Mecklenburg fly-V-,tir th&fnrgt, I-hemby,,cerhfy•#hir the ive)lpsj eras Arm)ahmidarted nr
(ouuti P�JrellJcntitlo:ili011140,(PIN) &xbrilancstriIVISA:X,ICO2C.I100.oreC.6200 MellCvnrhatcliufiStawlarels-
' ''frog!llrrit rr'c�,vv,af(his r'srurct lr�s beeia provitted la llrs tretl ourrer,
Sb.i.atititde and long wde.in dcgrie4 mleiuteP/seconds or dixiitud;debrecs:
(tf..,eiltr`td,ottc4ttlkt�i3� �titeic►�r) - 9.Site'di*e4inoraddittonaVivell.deUft
Ydu•itia5,rise tW bacl:of tlits,page.;to pmside additional vwd site details ouivell
ab;iuddunteu!details: You ttmy a[so attacii ndditiminl paei s:if necessan'_
QY)NS'I•itt[C I0N`.DPTAII_C OF WELL436 BEING.ABANDONED' :SLIRpi17'1'Ai,MT—RUE-WON-3
Affcxh trelL�na�trtrclrr�n'riKiud(sJ'Jf uvitlrarilq.;Flu J-1614c ixjettlnir iu-rvxr uxrtrr sirpp4i 1.
trcida ChVLt'milli L'xt avow-ertrsrnartrnuraLmee;4,rvttcvrt)za can nrGtwt iure ,im Itla;-For All_ttVcllc: Submit thi',c;form-ttithiri.30.4•s.of completion of'rirll
Ga We1IID
sr-33 abandoonicnttd'thc'f011oit� i
Division of fNVaterResourcm:iuformAtion-Proecs,,ing Unit;
2 5 1617 DIai1 Scrvicc Cctitcr,Ralciy fi,'ItC 2id99-16,0
GI►.Tofitwcll;deplh:: (iU}
tall.For Ittle don Walls: In.addition to seudiug iht form to the address to 10a
fc.:lloreltoledi;rutetec:l Gu,l :'above,also submit.otte copy oCthis font iv>itldil",days of-con)ptetion cif well
abandomricud to r6 fallawing: I
DivislottOf Water R6our+cts;.Undergronad injection Conani l F.Vogram,
lid,�'atcc icccl nciow mound suefacc:.to (ft.) I63G tllail 5cnice Q'�atcr,Raleigh,IlC 21G79-IG36
6a{Iuter:6sing length(if lmown): ( ) toe.For In addition-to:ending the.form to-
the addresses) abode:also subtuil bue cope of this'fatnt'tvitiiin 30 days of
comptction'of iveil-abaudonnicuu to thccomity ltsat4lt-delutrniicti3 of the cour>h,
Gf.Inner casring/tak.w-Icy th(If[arpvin): A)
where abandoned.
6v.SM-en length(if Lno►in):
FonnGW-.10 NanhCarolinaDepauncolofEuvlronmentandN:auralResources-DivistonofWaterkesoums RevisedAagust t3
4 '