Mecklenburg_Well Abandonment_20230828 (5)

WELL ABANDONMENT RECORD � 4
For Qrdcrrwl tltz ONLY:.
This form canoe used fo'rsitiglz or tnulliple ifells
1.Well Contractorinfonrtatioai )&UL.ABANDONh1ENT DETAILS
Brian Ewing 7a.'vumher of nclls being ultandnned: i
we]t'CorkricforlraaIL-6rita Law cirpe� A41j,:�awlatiln wilitm1&ht rvrapcny) For ntulopie h1jeelfar or
rwrr=mrtert sirnpt� wells ONLP wig) I& sane
caixhticreiNt'�hm"W61 tc�rai•lrlrr cj ur$rafwbf rxJr fain,
4240-B
7b.Appmiitm xte vi)lumc of water remaining in
NC Well CoalmdorCcillflattiouWirbcr
SAEDACCO FOR.WATE R SUPPLY'iYELIE S ONLY:
[Art ant}.Nance 7r,TAYie iif ii1A ietont uycd:. 1.
2:Well Consttvciion Permit 0-50000087,
lift irfl ryfpllsua)la ucll Eertnitr rlit C;rrar •Sig l�:d u'aivacr.Irrjerltca,ra'c t fffiifuwn 7d;11mollnt Uf cll�lnfcctuul uscll:' j
3.WO use(4b'ec1L Well nu):
War or SuppleWell: 7.e,Sealing titaterirtis usal(cite&all that apply):
l7Agri�ult;ttNl ❑htunic paliPitbl[c 12 Ngi Cenicnt.Griint 0 Acraonilc Chills ar Pellets
C7Urn1hcrinal a lHcatinglCooling Supply) ❑R ctiti,'tl Water$pfspf}'(sinr�lg) .�Saud CeitiettiGmnt _ ❑Uty Clay
❑Ltdustriallconuncrt:ial DResidential%Vaatcr Supph'(shiltcd) E3 CranctctdGrout ❑Drill Cittiiags
❑Irti lion - d7 Speaalty,Gruut ❑Gravel
Non--Water SupplyNVctl. ' Cl Bentoldre Slurry• 0 Ober(oplain under 7g)
Mmouitorine
inicttion Well: If.For.each material selected abovice protide amount-of materials used:
(7eCrjitifcrItecharQe OGriiundi}Ucrltentediruioti Neat Cem.•471b ,Wtr•3ga1: Sand Cem. lb ,Wtr•_gal
17AqUifcr Storage nix[i mtveiv t7SulihiiV Barrier j
OAiiuifet Tali DStomntaler Drmivage
0E erimetutil T1Yhitp[og4 t7S»hsir[cts:g CotHtn9 7p;;piroi &a brief.description oP#bc MWidatnment lmroaAurc:
Mbentherttetl(Claiscd Loopy 0Tracer '
TREMIE GROUTED FROM BOTTOM-TO SURFACE
®Geothermal(Hc afinWCoatiDARetum) 00thcr.(ex lain under 7g)
�'
irRateitclt[s).ithundnncil, 7-18-23 L r t"
5&Well location: 8 2023
Motiva 8.CcrNf[iatiau: I rh rR;e4cn Pr`^.,`a•*�;a
raeitiljlOrvrterNtinc Pxilih°IDstifnppti_Iblc) D�.W,
�.
UOG
6851 Freedom Dr.,Charlotte,.NC 28114 B.rla n E_. I ng 7/28/2023
Physical Addrem.City,and Zip Stctttlnsc ofC�.iiilletl�Vlaelt Era Y.ldi Yr.:'.11.(h5tr:r p;r1z
Mecklenburg Lly.signing tins•form, I hereby cerfify,dhat Ike weft{vJ,was(trere,abandoned
Corioiy Ccuialretctiun Stirntktt tulst
No tre n71h 51 AUC OC,U10 lr3C.0200 tVe1!Prect ld-nditicitio l al
and lkaf a copy offMis mcard has becttlirrot idad,to fix..ii-ed mvimr..-
Sb.Latitude and longitude in dcgimlrntintttesls oiods or dccint:l degr ees: .
(if.i•etl ford;am-101m,is s rtl3 kiv 9.Slt►i diagram or addlt[onat well details:
You may,use ilieback of this page lo_provi&additional,null sitc.d'etdils_of ivell
lt' «' Abandonotetudemils I'tititutiS also:ntacltudiiitionalpagesiftkcessan:
CON$'rRitC'0k'q DETAILS M WELL010 ligiNG.ABALMONE- b .SCTBhfiTTAi..TNSTRi1CT10�iS �
Atfaeh u4l.euas[rirrtiure'rctnr�fl$/y'�iiN7nGFe ,Frr mLlville byeCi oia 6r rxln-uYttirmpply
itAO.ONLY it-jilt&wnn.• sidlnmzi 6teiaiut 10a.Far All Welk: Submit tIlES tanir>i[thin 30 days ad'completion of well
6a We"IDg•SP-4 abandonment to ittb following:
6l4hinn of Water Rcunnmc ,;Iuformntlon E.rirceming.Unit,
6b.Totnl tsclldcplb 25 (ft,y IGI7 Mail Senicc Center;Ratlei;,h.NC 27699-1617
10b.Tar I"leetioti Wc[ls: In addition to sending 1hal4rnn to the'addrrss in 10a
6c.Borc1►olaa dlitntcicr:l • dip.} above;also submit one bolty or ibis fb j t within 30 days of completion of'aeell
abandonment to.the folldti•ing:
a
Division of Water Resources,Upder�ruund Injcct[tin Couttvl Program,
G.d Water let'cl.beton'ground surface: {(r:) I636 HAI Seines Ccnigi.�ItnlcigIt,NC 27G99-1636
loc,Rnr W:itcr Stmnh•.C-TuIsEttan 1V0.II1; In addition to sending the fomtdo
lie.Outer casing[env h{it lmnnn): (fG) the addtess(es) ab6m also submit one copy of this foi mi'tvithin 30 day8 of
comptetion of well abaraimunenf to the county bcalth dcj mrtntcnt or the courtly
6f.Inner casin•/ubbig ten)ali
*ltcm abantlon¢d.
6A:Screen length(if koon n):. (ft.}
Fome G%1-30 Noah Camllm Depauakrid ofEndronment and Niuuial Rcsomtes-Division of Waterltoomm Revf6cd Again 29 B