Mecklenburg_Well Abandonment_20230828 (7)

I
WELL-ABANDONMENT RECORD Farlmcrnulll5a0KY,:1
WS foist cah Ue used for single or inuhiple INUIS
1.Well.Contractur Inrortnation: ;RIML ADANDONNIFNT DFTA11:.ti
_Brian Ewing 7a.Number of ivells being,abiurdaJd: 1
tvolt'Coutricler aule(or+iellni add'egatistly:ahW-Ojtbouonbnluslltertnupcny) For rvidople 'Inferam or. "'WHIM& sry911.), we& ONLY w1Jri 1he sane
Mttymecrtinie(bin'.{ji71l7)L'?Jt,. ir1 epvr-mbn1t1 dGfirni,
4240-B
NC 14ell ConlraaorCetiiliallion Kinnc�r 7U.Apprnsiiriatc vitlume of vsa. �tnuiniu);in vvell(3)i (gaQ
SAEDACCO P4R WATER,SUPPiNWELJ,S�NLY:,
Qj1VW1y,Kanl0 7 c.Type of disinfeetant used:
2:%'ell Construction Permit 11:50000087, ,
L[�t u1f iyildttvble arlllmrmitr r%it l=+iltuh,State;l arlvn:'e.hrjrcrtiir;rtr.,f fJdtmwu � '
7d.Amount ofdisinfectaut tutu!;
S.Well use(clieckry a use):
Water Supply Well: �o Sealing m�tcrials tiled(chcd:'all;tlt�t uppl)); .
gAgricalttlreE gMnntcpall7'tlblic. IR NcaiCcrtictic.GM;t Ll,Hcwonitc-0141sofN;111etS
17Ccotitcumt(HcatinglC.00_lino Supply) OResidential Watcr Sup pff (sinr�lo) 17 Sand,Centeitt Grout ❑Dry Clay
❑bLdintrial/Commercial ❑ItcsidentialWAter Supply(shared) ❑Cotirmte'Grout I ❑Drill Ciittinrs
❑Uri tiou ❑'SpeciultV Grottt ❑Gratrel
Non-Water Supply�Vcll; C1 Beritonile Slurp' i Other(explain under 7,g).
mmotiitorine ❑Recovety
injCetion Nvella X For each material selected above,pr6ide amount of.materials used:
❑Atjrtifcr,ttcdtarge ❑Grrmridnaler Itentediatinn Neat Cem.•471b ,Wtr•3gal. Sand Cem.•.lb ,Wtr•gal
❑aquifer Stonige and RwOveni ❑Salinity Barrier
❑Aquifer Test [7S lomnva[er DrnWage
❑Etpetiutettlaf 1`c+cltuolnev pStibsids»«.Ccaftltni . 7 Provide a belcf iiiseriptian of the abandonment procedure:
06codicr nal(Closcd.Loop) 07fracer
TREMIE GROUTED FROM BOTTOM TO SURFACE
OGeothermal(Heuin�JCoolii!gRetum) 001her:(ex lainunder7g) s J_ —t ED
a.Datc,Wc (s).:ibandrinccl,• 7-18-23 AUG 8 gn9
$a.WelB lucatiiin:
Motiva /�;+�
racilitjt0vivrNairc raciliq'IDN(if'Itpplicablc) S•Certilli`atiaii:
6851 Freedom Dr. Charlotte, NC 28214 _Brig n .E_YY'n I. 28 7/ /2023
Pit+!sical Address.Cit},and Zip StLFtIhItC of(;entticd 1Vtti Cornr;tctaJ:,r'i::11 dwn:'r U;,qe
. Mecklenburg 1ljl signing this form, 1 hemby certify,dint 11m wells) wgir(were)abandoned in
Couuf) Parcel 1Lkfd lo6IlnrrNa(PIN) rici'onlauc'c ivah'I:Sr11MIC a2C.0100 qr 2C A200 I Ul Q ilstrticarin Slawkirels'
and that a espy ofthisrecorel Las•beeikpt rovir.ad,(o 11m.sell ouver;
.96,1,adiadeaud longitude in dempltninaies/sciorids or dseinial d0grces:
(if,+•c11 fvtd,ora:kllllnlb isa dricocty) '9.Site diagram or additioualwell detAm
You,tiaf i se the back of d6 page to.t t&idd additional tii�ell Mte.details'or rrell
A' W :abandonnLent&mik Youmaiv soaufacbadiiiiiouaftlagesifrkc sari
C(1IN5'CR1tCt1Q)N nF!rA1Ls OI+NVELL(S)iIIE NC.ADAN1146NED SURM1i17iTAi.iNSTRUGTi01T9.
llach ujr11 amah-amide recnril(s!V:ari211AW& ,F}r malaple L jeciiair fir J.�a=+vd1er S,ppiji
ueldsQVLt nitlrrlravnraevtLstnkripmdLarrelart9eut.��acnnarr&mitwre�Ginrc Ilia.Far All Welle•. Submit thLi fort Within 30 dafs of`eotnplction of urll
SP-7 abandoamicni to the following:
Division of Wmer RoAurces,Urfor•mation Proemsing.Unit,
25 IC,17 Mail S,ef%ice Center,Raleigh,XC 27699-1617
6bi Total sell depth: (f@.)
I.
Wb.Tar in ieetinn Wells: In addition-to sending the fgrnt to the-addu:ss[u t0a
fre.Boreftole diameter.l (u.} above.aLso submit one co(ty�of ibis foils witltiit 30 days of completion of well
abarulourilcut to du;•fcolldwina:
Division of W4,erResources,Underground Injection n Conttiil Program,Gd.Water lcvcl`bclrnv gmu6d strrfacec (tt:) 1636 Dlail Scri9cc Ccnt¢i•,Ralcihh,ll C 27649-1636
lac,Par Water Stennty&Uetectfan M&S. In addition to sending the force to
6r-Outer casing length(if Lmi Wn): W.) the addwss(esj abtiae. also submit btie copy of this brut wiihin 3Q days of
completion of tivell abandatumnt to the;county lwaith department of the comity
6L Inner easiaWtubing length(if lino n): 00
ey11=abandoned. j
6g.Scirma length(if known): A)
Fomi G1v-3o Nonli mtim Dkpanmeo of Pit+iroatncni&A N,uutal aesouzes—Division of 4latcr I1--ill`s Revised AlLgua 20 t3

WELL.ABAND.ONMENT RECORD l
For lrnernal l9st<ONLY:.
This to can W used for single or tttullipfa isells'
1.Welt:Contractor Information: 1VELL ARA11DoNt*1FNT DETAILS
Brian Ewinqr7p.Number of Wells being ah"duned:(1
4Vc1t'CorYra'cfbrt\an�(orttielloxnerkc5oriall aL,�'a3d' uo6lanliEsll,ee ,u cri For irrulopla NJerttar iW rsrri-ne,Pe i•s,rp weflr ONLY With tie .swse
• carurrrrcoi�ui�harriiruir»«rl,,lYlrilYYP9�l�;Jllf�refrirnr,
4240—B
AiC tiYcl1 ConlraEtart rnlfipdiriu Nun Gcr 76.Apprrixinwtc Volume of fixate•rx4 Wig in yscll(s)i (fitL)
SAEDACCO 1+OR.WATERSUPPLY WELTS ONJUY:
con�any trams 7e.Type of disinfectant ujr.ed:. i
2:1Vell-ConstiuctionPermtttl:50000087,_,____
Lt3t irll rrp;ftvblr lee ll feneftti(i.e_t�wrYy,.Slide,l orlia c.I1 jecriUir Nlr.1 1JdanuWlr_ 7d.:lmount of dlslnfcctrtnt>!.u'd: �h
3.Well use(ebrdq'e11 uae:
Water Supply Well: 70-Scaling rhatcrials used(sired;all ihat apply):
pA�ricirltttr tl I7ltifrmicipaUPublic fed T1cat Ccnicrit.Gn tat I p }3ctrtv>iitc•Cliips or Asllets
Mko..thermal(HcatineCovlino Suppl}} pRcsi¢ential tiVaterSupnt} (singlo, - p Saud Ce Had Gmut ❑Dry Clay :
pindnsttiallCommcrcial 1311csidential Water Supply(sharod) ❑Concr>to Grout ❑Drill Cltt4iygs
pGii [ion ❑Specially Grout .O.Gravel
lion water Supp;y Well, p 13entonite Slurry ll Oiher(explain uuder'7gf
MMonboritre ❑Recnyen
Injection Well: 7f.'For each material selected above,provide amount'of.materials rrsed:
❑rCq'uiferltccharge ❑0 'undn:ucrRt nledinticm - Neat Cem.:471b ,Wtr:3gal. i _ Sand Cem.:lb ,Wtr:gal.
[]Agtttfc Est'tagc take.l3eriivCi~ ❑Sriliiiity Barrier
❑Aquifer Test ❑Slomryy liter Diuir,age. °
l7E,y�erintentel�l`erliuplogtr pStibsidetzte.C4ildntl 7;Y Frn�•ide a brlcf•dcseriptian of fhc iib;iudnntnent proci�dum:
t9Geothenlutl(Closed Loop) bTracer
Mmodwrinitl(Hea in&Coofina Return) ®Oihcr.(ex lain under 7a)
TREMIE GROUTED FROM BOTTOM,TO SURFACE
J:Date yrc1l[s)abpndm►ed; 7-18-23. t L- t u t VC
i
1L Well location. AUG 2 S 2023
Motiva 8.Ccr�iRcatiou: Irt�rara iC;t �r �.Uni
Facilitj,thvi>zrNnilc FxilitylDe�filppliwlilc) I DWQIBOG
6851 Freedom Dr—Charlotte, NC 28214 Brian Ewen •r,'ng 7/28/2023
Physical Addrem.City,and Zip $i�hliLOf Cciiif w 1Vetl Cam4(cli�s ell O;Vrgr D:nc
Mecklenburg Lty.vignhq this finrt, I hernhy certify that dw,rellfq) wax(wore}ahaidared ill
Cowsil Paccclldcnlif illnnNo:tPIP1) ttccwxldnii will?"114 GuistrictionSfincktrcls
and llral acgpygf11Vs record hasbeerr-prm t'erl to llre,+ell otrner
Sh.Latitude and longitude in tt4�cyrntintttcs/sgirrnds ar decint;il dot ccs:
pf�en Cstd,clue 4�tl141'g'SAII 36all) 9.Site diagram or additional well details:
You map.tise tt e.bacl:pfiltis page to provide-additional well site details or null
R w :abundonuteatdetails. Yoti tu>ip also:etaclt>illiliGoital'pages ifricc�ssart_
CONSTRUCT-ION DETAILS OF WELLS)BEING ABAN60NED StiIi14Ti7TAi.-tNSTR[1C LIONS-
Atkkh oIwl cx,nsbwellew ticnid(s)lj pr nir�7Lra ,RKP mndopb hVecriioi:,LU LvJtl•ilxrlir xupplp
u elfs O:VLY,rJdi v're astnR aY»ciLsxflorcu!are,Aorrr�rit.�oa ran sirlrrir Cute fours 10a; For,All Wells• Submit this fomr itiittun 30 dkV5 of completion of well
6ai Weft @§•SP-24 abatuinnmcnr to thc'foUoainr
i.
Division of11'uterResourcm.btformation Processing unit,
iti17 Mail service Cenicr,Itttleihh,I\C 27G99-1G17
6b:Total well depth: 25 {ft.)
lob.ror inleellnn We11s: Irr addiliou to sendinil the form to ll,e addressda IOa
fc.l3tirelroledlaateter i abow'also submit One topy or ibis fOrm,SSillAu 30 days df completion of well
{iu:)• nbalidamrtcrU to t1u,Polhiyiiva:
Division of Witter Resources;Lipderg;ra>uad Lijpilon CoutiolFrom gra ,
fd.Water tcyxl helinc gtaririd strrfacet 00 IG36 Distil"icc Ccnici;Raleigh.NG 2769-1636
f
6c,Outer casinglcrtrth(if Lwtn a): (ft.) 10c,irnr waver S,tnnly &Taicetlon•1Vclls: In ad(idon to sending the foini to
the addresses) above. also submit one copy of this form yiithiti 30 days of -
completion of Syrll abarulormtem to the c+o ly health dcparinicia of the county*
6f.Inner easin�Wtubiag tength(if Imawn): (it,j yidicrc:tbartdoncd. �l i
. I
6�.Scrr:eu length(if known):
Fano G`,Y-30 Nouh tamlim Dcpannx.ni ofBmvironmcnl and N:uumtResouzcs—Division of Watcrlte-sowces Revised Augosa 203