Mecklenburg_Well Abandonment_20230828 (3)

NYELL.ABANDONMENT RECORD rimcnalVWOAY; f
11tis form can be used fbr single or intfltiple vFefls
1.0][Contractor information: WELL ABANDONMENT DETAif_S
Scott Hunt, Jr 70 Nttmticr of wells he +� 1
.allandoned:
1}Tclt+uulracforNagtc(grwyllo�it p.rsm�tlyalmmfot�retis tl.on)ii9tltcrprdpcny) Av, rraulnptP tgfecuorr or rratr-yu4fer supph,' WjM ONLY with ,tke' •swiia
coa4rrtrcfioairbols(wjtlaurt,jrrrr ar,�ufyuit,xr.xfoPnt.
4561-A EI
MG Well Conlraaor Ccnitcrcalion.Nanabcr 71t.Anpntsimate�nitime of t Fah4 e�maiiein 6n�i'ell(e};, . (;,itl,)
SAEDACCO 'FOR_ WATERS.E)PINLY.WELLS ONLY..
Convany Name
7e.T�'pe of disinfi+cta utied:
2;WdlConsttuctiaoperinit(l:50000087
[1st irll vftpRcvLlr urfB pePtnitY�.e.Ceutttrr,St:ter 1'r r&irrer,rlrrlipi rrcy ffJfuru�rr 7d:Amount of d_is_hifi`ctu_nt usrtitl
3.Well use(chedivellusc):
Water Supply Wq: 7c,Scall4g i0itclUlsvied(Cllect A'that apply):
❑A,ricitttural'. Ahftuiicipal/Ptlbiic ®NeatC¢mcat.Grout is Bcmoaita.ChipsorPcllcls..
❑("ietilwax,ll(Hcatiur�'C.00litig Supply) ❑[tcsidcntgit%fer,BUppi}'(single) ❑.Sand Cement Grdut D Dly'Clay
❑indushialfCornnicrc%l• AR_esiticntial�Vntc_r Suppt}'(sltaial)' 17 Concrete Gt"t; . . - E3 Drill.Clitfings.
17iti1 'fion ❑spedally.Grout ❑Gmvel
Non-WaterSuoply,'4 eff. CJ Bentotute•51i[ti� Ci Othee-(e�plainuticierlit)
17149ot)itoriite•- .. Q9Racoven. � .
injection WcU- 7C For each tuatcr d setected'ab sick proAdc amount of,materials usc&
❑IquifeelI I. - .iQe ❑Gtottitdtt tlerl8entedltifion Neat Cem.:471b ,Wtr:3gal. Sand Cem.:lb ,Wtr:4a1.
DArli r Stotuge aid,Rzcovery ❑Salinity Birder
❑tAquiferTest. 17StontnvaterDttttnage
i]E�relimeittal T�lutolo�r I]Subsictet>ee Cotusnl
7g:Proiidc`a 1►cirf dcw:iiptiou.pf tlrc alitadnnment.prr urei-
Meothenual(Closed Loop) OTracer `I'
trimie .grouted bottom to surface
❑Geothert»ti'(IietttinttlCo0INZRetuml ❑other(en lainunder7 )
.4.Rate well(s)abandoned. 7-17-23 t 6..t WE
a.Well lgcatlon. AUG a S 209
Motiva
R:Cr niRcatlatc Irii`Crl�aiCil ?r;t.54
15tcilityiatvtrbr Nurnc mild}tUa�fappliwblal Di►iOi✓ +�Ura
6851 Freedom Dr. Charlotte, NC 28214 �� 7/28/2023
Physical-Addres.City,and Zip sigml trc OM TOW Well Owtlrmor. vefl Oivmr D;ue
Mecklenburg, It}r si}ettlt{n�.1hi:4 finis, 1 h. mt,,ycev ify tAar lire inditO 1fas( erq)abodated.hi
4ouufy Parcel.idctUiffi=tl.Mt No;(PIN) obit/dance 1Pith l&l AVAC 02C 4100.,Dr 2C.0300 Well Conch icliori Stawhtrds -
rmtlllrtrlucpPi�nJ(ltitircaorc�)tusbettopraviderllo!!re'trcllolaitet:
ill.Latitude and longitude in degr+ecslmiouttea/seconds ordccimal-Acgrecv:
(ltxYcu l bttl+'OIM;11t11P11�IS�1dt1C0.t ) 9.Site di,agr m or:additional welt det Ills:
1'tiu nt i)uge tiie 13d1 of this pEigelta provide-additional nell site details;or hell.
r' �Y abauditnntuddetatls: You ntay ul§a''attach esklitiatiol pates if 0eC ssat3+_
CONSTR1[C' ON D&ADLS(IV WELL•M 6EING ABAM)CjVED SImtrrrAt,N$TRCiQ_'t'rONS
Afyat,h well.,mra PneflJ•rt reznrdtS.t if aiau!lwf k..licw trn,1hp!r byigarur'ixr•ri' .,,j ,tu'.wjtpli�_
n /ld ONLY trlfh the svui�+cu+ratnrrtoit nLiveikurriirnt._izre nrn ad+mit'ww fu�rr 1031 For All WeWk, Submit lit ifarm iiithin A dkv-..of.cdtnplCtion of-*C11
6a.Well IDg.SP-2 abindonnicni to the tbitonnrig:'
Dii'iaian of Water Resitnreesi.inforsnptilin:Procesilgz Quit;
1617 3140 S"Yice teatcr,MdrjiAi-NC 27(i99-1617
6.11.Totat well delith: 25 (t>t.) " '
tub.kn rutma tt was.: hl-addition to seudittg llie fornt to the addtt:ss-in IOa
6e.Borehole diameter.). (;n;) above.-u[so submit Otte copy of this form'iviiltiit 36 dayj of cmupletion of treu
abandonment to tlrc fnllauing: I'
rti.water 10 (fr.) lmgstun of Waleri ese'Urces,'Underground Iu1wrou Control Pmgr4m,
1636 N1.10 Scri m Cc'nter,Raleigh,NC.2t699-1636
10c For Watcr-Sttnnle.f'role n in WeI1s; In additianio sending the fort to
6c.Outer casing Idvfi.(if known): (ft.) the.address(es) abode. also subn itj bite cop}• of this'•f0ml within 30 days of
comptWoti of wcli•abandattmcm to[thccount} hca[ikdeliattmetd of the county
whcm ibatldoncd,
6f.Inner casiogltubinq:tmwh(if linowny:
fig.Screen length(if knoisn): (ft.)
Bann G1v-30 Noah Camllm Depaumca ofBnl drontncnt aW Naturat Rcsouxes-Qlvisfaq of vratcrRtq I utb.s [tevised August 21M

WELL ABANDONll�IENT RECORD Forhiieritul(i9ct7NL�',`
Tltis foiin sari W tiled for sipgte:or multiple wells
I.Well Contractor Informutiou: WELL ARANDONMFNT IDETAMS
Scott Hunt, Jr
7:ti NutnUer of hells Ircin>;alr:urd.�nivl: 1
WcliCootmctorh'anro orliglloltirrr"^isi�liallyulrando %%A.anhistltcr c �n Ru• .umlapre 011i'lifti or iwn=ridrer .supply rrMs ONLY with Am;, saiie
( � �' lu'p`9) caistmcrtrwu�anfoinva�att,'�nntitues;ihliNt�.vr.�fiirrr�,
4561-A f
7b.Apprgt imatc valunte of•wrat�`rVini niu�in\S'eIt(s}., (gitL)
NEWaII'CoulgorCailificalion.Ptnrribrr i
SAEDACCO FOR WATER SUPPLY WELLS ONLY
Cant my Nam, 7e.Type of dislpfi'etaat*ww
2:`VeliComtructianPemitN:50000087, ,
Lst•tdrntprhrrtrre.aru.;nrmraYG'.d_Cuanm,5tw1z.drat,inee.Lrjectioie,L-tc.}tfFrmwrr 7d _tttioatttuCdLSinfectslutuScil•.
3.Well uge(che&well'use):
Water Supply Well: 71P.'Scaling inatedaikuscd(check All'drat 4liply) '
pAgricidtntal'. pMtmicipallPtlbtic DO Neat Cenlcut.Grottt 0 ecotonilc-Chips orPcllcts
00M.-lb6mvl(Hcatinr�'CoolidA$iiPply) pftcsidCntipl Wafer Sitpply(single) 0 Sand.Ccntenl Grout 0 Dry 64Y
191ndnstrial(Comntcrsial ORcsidenthd Water 1rppt}(slut�l)`, D LbnctetcGiuut• I 13 Drill Cit dud.
MItti io-a 0 Specialty.Grout 0 GM%,Cl ..
Nan-\Vatci-5upltty.Welt: 0 Bentonite 5lilM- 0 01ber(explain under 7g)
OMonitorhre E9Rmcaverir
Injcction Well:, 7f.For each material selected abia`'1~;proAdc4niounfof utaterials Wed:
OAtluifcrEYec(rurge I70rouirdnalerllCntediution .Neat Cem.:471b ,Wtr:3gall. Sand Cem..:lb ,Wtr:gal.
LIAgttWr..Stomgeutdi•Irecove:3• ❑Salinity©atrier
❑Aquifer Tod 17StonuwaterDniirage
DEleritneitlal Taclmolov LiStdisirlet>ce CdrMtn!
7g:Pitllide a ltrkf description of the.abatidunmcnt prticedrrre!
Meothennal(Closed Loop) Mracer I
trimie grouted bottom toisur£ace
®Gcothernaal(Iieatin}r1C000BP,Retttro) ®Other(g lainubder 7$6
d..ilatCWCU(gabandaned: 7-17-23
$x.Welllocatlon.
11►fnrcr�;��irk!
Motives fl (DVrF LtR
FdcilitgiUi4nor N�uue Facilii}�lOa[Evpplicablol •CertiRcation:
6851 Freedom Dr. Charlotte, NC 28214CidL�G� !. 7/28/2023
Physical Address;Gitp,and Zip 5i trill ;orce1 1 4 Well C01110. ar orf Wll Oinur. pule
Mecklenburg If}r sib tt{�:thLs fFirra,,.l lremby eer•ly,giar tits wellpsj Oas.(leers} rdaied.in
Coautr Parcel Idcniillatll)a No:(PM ' abe ifrxlgnce irifh-1 ZA XC4C{)2(:,0100 orX'4200 Ti'ellConstivClioti-Sfaniktrds-
rurit That n't)pp}�of jlt s+acurrl.lras been jtr'vided fd i/ts wellcnsuen
ib:,I:aHtndcand Ionghttft:in dcgr�ccc(otttiutcslseciinds or dccim;il•.desr+ecs: •
(Irmell t-itd,arrc star ing n.sirlricis�>i) 9.Sitc diagram of ad'ditidnahicll details:
You tiiay'use'tlk back of This piige,ta.ptovide addiliotial stall site details or.well .
11' 'FY, abat►danute�itfletails: Youu>n}•atsojattacltsisldiliutialpae�sifnecessary_
irCiNSTRIf(.`8 ON UETAIL5 OF WEL1(S),BEING ABAM]oNEw "RMNtll"PAi,i .MUCTiONS
1ltrtrie urPl:ev,nirractiArt ncvrdrs%1)'avriiloLfd_. Fur uarllijrlr ufettlriir iAr rwn•uxu�slrpprj
uxrde ONLY:rrNSrl.�svri�e-cmrsr,racnurdoL,ur�fuxlr,rnr.�,iacan�rLmitiu fuam Iftfor.All WdN .Subic tltis'fbrm icittiiu.30-days of coiapletian of well
Ga Well •SP-32 abandorinicni to the fo.11oiO4e. .
Miyianof%VatcrRcsouirts;:tnfo"rn atn►m:ProccsLtinzUnit,
16- t617 Mail"cc CCVter,Ralcigfi,NC V699-1617
66.Total tsell.deptli: {tit.)
ob.-Irmr ialcellanNcIls: hpaddition to seadingflk form to lice addten hi 14a
6c,�Bomkole diameter l abavv--also submit otte copy of this torm.ii4tlrti►30 days of-compteliou of a ll
(iu,) abandountent to the follutvi
6a,Water lew.below groinsd nio f i ea,io (f�) Division of W:+tcr R tiuo cis,iinilcigrouad lnjet�iou Cottttvl Prti7 ram,
• 1G3G R1ai15Cri�Cc Centet•;Raleigh;NC:�rG99-IG36
Gc Autcrcasin le® ii-{if lronsvn): (fL)- I0c Fno�Vatet Srmnls Rr 6riectinl tYetls; in-addipan-to sendi"the fomi to
the addresses) above.also subnlit one copy of tills`fotut Nvitliin 30 days of -
completion of rvcl labandaumsnt toi'thc county heidth.departnICiii of the a aunty
Whcrc abanioncd,
dr.Inner.casiawtuliFnA tcngh(if 6•nawn): (ft.)
6$Screen lettt(tlt(if hnowt): (ft.)
Fenn MI-30 North Catulim Depanmcm ofEnviruament and Natumt,Rcsowces-Division of Watcrltso wits Rcvi O MA0 20B
Ir
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