Mecklenburg_Well Abandonment_20230828 (8)

WELL ABANDONMENT RECORD For lmcnwlUseONLY;,
This fo na chn be used.4'oi single or multiple}sells i
1.Well.Contr,actor htfotinution: UVFLL.ABANDONMENT DETAILS
Brian Ewing 7a,Ntmdter of ivOls being alrimddutd; 1
SVclfCouractarhauei(ortrclloutiLri�cemially=ab5nldtdtrgticElanlr�tlt rpropcny) For rmJnpie tnrerNar or m,rr-v¢uer suppj, urlls ONLY wrtb N.r same.
. roaxmrctiauirh�rrri�7rirvr*raf,1+'irr clvr sralvmt ar�frrrvn
4240-B
NC W4 CwtlydgarG9nIficttiouNtin bcr 7b,Appro%nnate►iiinme r(f IVAtCr iri;lining in
F
SAEDACCO FOR 1$';kTE-RSUPPt,YNVF.E.SONI,V:.
Com�i�tl.Nanic 7e Type of disinfectant used:
2.RVell Censttvction Permit ll:50000087,_,__
Id3t id1 rr iQ�tr rGlt r�rll Earmhr tl r•Ccwrily,Srair:l iJ'rl i mre.L;rfiitir;rlc/if kmuwJ� X Amount of&Infectaut used:
3.Well um (checkweti use):
Water Supply Yell: 7a Scalingmatch:ils usctl.(checl;allthat apply):
❑Agricultural OManicip;tlrl'uhlic 12 Nwt Ceoiclit,GnJot El 13emonitc`Chips or Pellets
❑Cicothcrm;tl(HcatirtclCoollug Supply} f]ItcSidcntilil l4ater$nppl}(Sinalq) Sarti)Cetrteotl Gtiint ❑Dry•CL•ty
❑InttiistriallCOmnicrcial 1311midemial Water Supply.(sbarrd) ❑Concrete Giout ? ❑ Drill Cutiinp
❑itri tiou d Specialty Gaut ❑ Gravel
Nog-Water Suppty Welf- Cl Bentouite Slurry 0 Other(explain under 7g)
lzMonitorine ❑Rccotrn'
injection Well.. 7f For eaelr material selected above,pimide amount of.ulatedals used:
❑Aquifer Rccbarge ❑Graiundn iter Rcnteduttion Neat Cem.•471b ,Wtr:3gal. ', Sand Cem.•lb ,Wtr•gal
❑Aquifer Storage aixl Rmbven; ❑$alii►ity Barrier
❑Aquifer Test ❑S lontnt'ir[cr Druirtrge --
❑E�cperirneulbl litihiiolo t+ ❑Sibsidew!Cprtttdl 7;.,.Provide a Uriif&%criptian of ibc aliaiidnomcnt prr►cidun:
t7Gmfierinal(Closed.Loop). riTracer
TREMIE GROUTED FROM BOTTOM TO SURFACE
06mtkriml(Acatin;'Coo6P,Return) ❑Othcr.(es lain.mder7tt)
--- -- - -- �'' d�''�' 1 �•,+-..try,
4.Datencl[(s).;ib;mdnncd;
7-18-23 r
5a.Well lucutiitn:
Motiva rlit3ftl.t►Nc tt Pr.^..-c&&Q ,g 11R:4
Pacilit lOwtu:r Neim Ta ility IDa'(-10pp5;610 .$•Certificaiioiv D1 QIP_.OG
6851 Freedom Dr. Charlotte, NC 28214 _Brian.Ewi n 7/28/2023
Physical Addres.City.and Zip Si�;luie of.'060HOe Vdl C6,rurr.kir:)r•r:;tl Ownx Dale
Mecklenburg flp:siglatng this foray, 1 frelrhy eerdA,,-tliat the teall(s) inns(irere)abandaied.in
l aursq Pared Idznli[igtlnnNo:(PRv) .'(icixrrtfarcc Willi 1.M riVAC 02C''0100 or 2C.6200 firrll G•ohvoiclium Sianikrr(ls
and that a copjr afthis record hasbecrr,proi iy'ed to llre.ii'e11 owner.-
Sb.E.:•ttihide and longitude fit rtcgrccsfntinuics/seconds or dechnal degrees:
(if,tV11 Ctld,girc latllnn iz,itlic6ci>i} 9.Sito diagram or addidonat hell details:
You nmy tk�e t1N back of dus page top rovide additional tciell site'.details or well
D' W 'ttbandonuieut&tails. You way also allech a'IdiGoual paves if riecessaay.
CONSTRUMION DETAILS OF WELLS)BEING:ABANDONED 9tJ8 itTTAT.INSTRUCTIONS
.titrxh�iirQ[na,rt+icritln mcvnt(sr lf'�iialli�lilr. ;f�4r mulorrr�a it jrctiair nr rsrn•uuter.firppij - -
u,elk O:VLY i0ih Am s,rin�crrn+renrrtorr<'ri4nrml@rrr r�ru•i�a cma srilmir ore krmm 10a. For.All W&Ls- Submit this farm �itlun 30 &aVs of eouipletion of Ivell
6u WenQl#•sr-18 abandotnticm to'thc following:
Dkvisian.of Water Resourrm information Promsing Unit,
6b.Total tscll depth: 25
1617 Stail Scivice Center'ILrleir�ti >tC 27699-1617
(ft. - '° '
10b.Tor miectlon Wells: In addition to sending the fRrnt to the address in [OaCie.8o;eholc dL�nteter:1 (in.) abiive;also subutil one copy or This fortrr ivilhih 30 drays of completion of%ell
ubaddonrrtent to dte,follti,tiing;
i
6d.�llater level below gmand surface (ft.) DivisIou of tiS'nter Resources,Uuder7_round.in jecilou Contra!Prxigram,
-106 Mail Scivicc Ccnict.k4lcigh,IBC 276994636
i
6c.Outer caiing length(if linown): (f{} 1(1e.i nr.tiV;rrer Srrnnly&iniggL2n Welts:. Lt addition la sending the fomt.(o
the addresses) aboye. also submit one 'copy of this.form within 30 days of
completion of mmil abandormi-ant to thelcounty bsilth dcp:artnicrd of the cotmty
dL ln=easinWtnbing length(if latmm): (ft) �i'ltero abaru oncd,
fig.Screen length(if known):
Faint G111-30 Nanli Camlim Depannr_m of En iroanicnl and Narwat Res4u.•ccs-Division of WatcrRoawas ttcvucd Augrsa 2013
I

I
WELL ABANDONMENT RECORD
This f0n canine used for single or multiple Wells" }
1.Welt.Cnntracier ltllfornintion: W V LL ARANDONNIENT DI TAIG.S'
Brian Ewing 7a,Numiter of 1vells being abirudaiL', 1
5l'c9tCortca�tortr`amc{ortl�lowttrjictSoriilly:ltUs idt tseltnnlig -r.prapcnyl Feu, w1dople U,1crJiar cv rv,rl-rrtrt`cr, "srrilv1, weds ONLY with 116L wire
. .cmtYfPrfOtJixu( rarl�rJJirutRlf,•lYlrJ Lyur T-AyJtlf atefirm
4240-B
N6 Wc11 CanitactarCcniGatliou Niiutrct
7b.Appmx3inate volume ut`itat�•�mttining in tivrll(s} {gal}
sAEDAcco FOR NVATF,-RSUPPLY�YI?LLS ONLY:.
- 1.
Contlrany.Name 7e.Ty lie tit disinfectant dyed:
2.�Vell-Constivctiou Penult 11:50.060087, _
6L+1 i11!ti)Jpltrnbla aeNtarmitr(1.e_CwuJh',Sl4le.J'urthrce.Lrfertiat ctc:t fdslllWrJ
7d.Amount of disinfectant used:
I Well use(Oe-di.well use):
Water SupplycWell; 7e,Sealing iitatcriais timt(dtccl:all that apply):
❑Agricalttml 11Nluni6p,•t1Muhlic �Nqi l cnieut.Gluttt la 13 monitc Clitps of pelicti
QClca}thsrtnal(HcaSin�rJCaalino Supply) ❑Residential Water Slt}rlt1�'(Singlg) m Saud CeinctU Grant . ❑Dxy Clay
❑hutuslrW1Comntcrcial ❑ esidential Witter Sappl},(shared) ❑Concrt:(dGrout ❑Drill Cnttings
❑Itti tiou d]specialty Grout .❑Grave]
Non-Water Supply�VcIE: ©Beotonite Slutzy J Gthpr(explain under 7g)
�Mmillndne t7Rt'r:ot�ty
injec-tion well: 7f Foi,.each material selected abase;provide amount of.m:rtr-rials used:
❑AquifcrRccharge ❑Gr►iundnaterRetncdiatibti Neat C"em.:471b ,Wtr:3gal. Sand Cem.:lb ,Wtr:gal.
OAyuffer Storage al'A Rccovml 139alihit)v13anicr
❑Aquifer Test ❑Stortnvvatcr Drahuigc.
❑Expetimetdtil T whunlogv ❑SuhsittetLe,CyiHml 7*I*mvidc a brief discription of the!'ibandunment prr►ci•tlutr:
❑Gcoihennal(Clascd.Loop) OTiacer
TREMIE GROUTED FROM BOTTOM TO SURFACE
®Geoihem>at(HrwtiinwCooliuit Return) ®Otlter.des lain under 7s)
i.°Datencll(s}.ahandtinctl; 7-18-23 F= 90
5a.Nell loeniiim
AUG-IT., n
2023
Motiva O
8.Certllicatloit:
Paclit�/thv'rn:rNwnc � ra.ilitylDp(ritpplic�Ililci � � lrllriNN",&al`�;1 ref,^•t'�ta�i'�t;tti
.n r
6851 Freedom Dr. Charlotte, NC 28214 Han 1 1 E_VY I ngr
Physical Addtc4•City;and Zip Fiiniriiest!Cciitliivf tiV'11 Cmanrtei,��WAI Oivwi Dale
Mecklenburg Hy si•SJJing.thu figrm,.1 hernhy cerhfy�,lltnt the trelifs) tins prare)ahandastrui in
County Pmecl ldctnifik i0mNo.(PIN) ticivtrlunCv wille 11A IMIC blC.D100.or 2C,0200 DWI Coiislnlraws Shinikrrds
mrdllral6espyoflhls.recur•rllrasbeatproviewdto the.Well otrllrr;•
5b.1„ttitude and longitude in.dcgr'cestininutes/scio.nds or decinW.tlC'grscs:
(if,vell fix'[Q;ctta 9.Site diagram or additional well details:
You ma}'.use 11k.bacic 0,flits page to provide additionai%vel]siti.detgils or will
A' NV ttbaudotmtetn derails. Yoo 100),also:ulan:lt nddi6onaf pages if D'ecemn,_
COWrR11C TION DETAILS OF WELL(S)BPI NV.ABANDONED 4CIRATi7'1 AL INSTR[Tf TTCIVN
uruh 91r17 reared velielrJ"recordlo J)',uvW1&rile. ,Fein mnlrilik injerdent or rnm-uxdw;wpplj-
uellzONLYvliJrt!wavnr�•rrixtUrxtinnrt5arieham:lrrtl.�.sncansrilumldtre�Jnrr Vim For All Wells: Submit thEs form>,iithiti 30 dtWs of completion of.trell
6s.Nell ID#•SP-22 abandouuii nt to'thc-following:
i
Diy-10an of`Vaterllesnurcea,Informption Processing Unit,
1617 Mail Smnicc Center;Raleigh.NC 27G99-1619
6b:Total well depth: 25 (ft.
Tplt.J,or in lc'rtfon Wells: In addition io sending lire fnfan to the address in.10a
above,also subudi one copy or this forin vYltbin 30 days of compleliou of%mll
Cie.Boechalc di entetet;l
(iu.) abandonment to the following �
6"d.Wutcr tevel.hclnty ground surface (try Division of AYnter Resourcts,iiutI ground LiJection�Couitu lPrdgrtuu,
163e.Diail Scivicc Ccntcr,I$lciwh,NC 2769)1636
i
t
Gc,Qutcr casing length(if known); (ft.) lac.T'nr MjS.r Surmlv..tr Toicctinn Wells; In addition to Sending the form to
the address(es) above. also submit one:edgy of this form within 30 days of
completion of well abandotunenl io tlic'rnunty lwalth depurintent of the county'
6L Inner caiinWtubin twigth(if lmuvvn): (ft.)
�vherc abandotycd, �
6 .Scravrt length(if tmovvn):.
Font W-10 WfilfCarollm Dep;ttt ird dfEmironment aai N:uttml Resomucs-Division of WaterRmumcs Rcvfsed Atup o 20l_c

l �
WELL ABANDONMENT RECORD For lmcrml Us*ONLY;
71tis fotnt can be used for s"tngle or multiple Ssells
1,Welt.Cantractor Inrormation: WELL ABANDONNI[EN'TDETAILS
Brian Ewing 7a,,Iumlrcr of Melia bring all Urdu ied: 1
%%,ejr6LIIrcforranrc(ortti61lo%vwj' $mull}; nnitisArLrttrupcny). FN• w1dople. 61[evilat or' nwimarferi sryjf�. idells ONLY will) Noe same
'' cxrraxmrcre�r�rharr�ruirnr�+l,,l4lrt LyYr4AlRJl+f dVt6�JNl1,
4240—B �
NC1ve11ConlraaarG.n iT aiUou Nit utG cr 7b.Apprnsituate,9rlumeof*aterremaininginrecll(s)i (�i►L)
4
SAEDACCO FOR.WA•1.1~R SUPPLY tiYFWS ONLY,
Ca+atpanl•Nanc lc.T)ytc of disinfectant uied:- I
l ,
2:Well Construction Permit 9:50000087, ,
l+3t till t+lapl c�+blc a v1PEtrmitr fir. oLrJY,Stair:I urlrarxe.Lr cdtui�Ntr.l If knur�i+ 7d.Amount of&Infeaant used:
3.Well untie(check Well nse):
Water Supply Well: 7c.Sealing materials used(clt&all That apply):
I.I ,gTiCulgv tt ❑MutaicipaljAublic. R NGti Ccnicirt Grgttt Cl Rcwonitc'chips or Pcilcts
❑frcothcrmal(HcatinNC4olin,Supply) ❑R;.WcntW toter�iapply(s inglc) I]Saud Comeau Gront ❑ Dry Clay
176afustrialli'ommcrcial ❑Residential Water Supply(shared) ❑Cnucrete'Grout ❑Drill Cl_iltinp
❑irri tiou ❑ Sp�clalt}`Gruul ❑ Grs�*el
Nun-Water Supply Wclh ❑Bentonite Slurtp ri Otber(explain tinder 7g)
�Monitodiaa ❑Recot�en '
injq-tion Well. 7f For,each material Selected ahovcC prioside amount'of-matei ials used:
❑Aquifer.RCCharge ❑G7trtlladt}:1(cr Itcntcdiatiori Neat Cem,•471b ,Wtr•3gal. Sand Cem. lb ,Wtr:gal.
Ej Aquifer.Suintge and Recoven, ❑Salinity Barrier
❑Annifer3est• 13Slormwaterl1rainagc
❑Experimt nlai 1`cthito[ogy ❑Stihsidet>re Coitd. ?*Prn-,idc a brief d6cription of the abandonment procedure:
63codiennal(Chiscd Loop) OTmCff
TREMIE GROUTED FROM BOTTOM TO SURFACE
®Geathennal ffltltiosXoo ling Return) 00(lier.(ex lain tinder 7g)
75
d.Altcncllts)abundrinal; 7-18-23
:.� � : '
Sa Well Eucutii►n: AUG 2 R 2073
Motiva
ramft/rhvwrNmrc FatilitylAb(Thppli_iblc) 8•CcrtiiT alioii: Ifftr,Y'Aicrt?rCt�}X,3nwg Ur 4
• D(Pr't3l OG
6851 Freedom Dr. Charlotte, NC 28214 Brian E.in. 7/28/2023
Physical Address.City.and tip 5ti mIitic f(;eaiilita 1beII 0<w1rnIdi:rr;11 Qnwr Mug
Mecklenburg Ry signigq this farm, I hemby Certify llwt the trell(.SJ mwv tirere)abtuadaned in
Cauet} P4rceildcruifikjlanNo.(PIN) ric�'utdrb+cent!lrl:iil.t.LrlCO?C;(li¢lltir7C.0�00IVellCaits7ralGtiurt5tciniktrrls
and Aram o eop),oflhis record Aasbee+a,prmilrad(o fire a+-ell otr++ca.-
Sb,Is:diode and longitude,1"t[a necslntintttes/seconds ar.dtxint:il tlet rocs:
(ift�@tl fm 41,1�uc l irllaug:ic nllic cry) '9.Site.dingram or additional well delaui.
You Inky.use tlie:hac&'of"dais page to pio�ide..additional well Ate.&tiils or ttrll
N W :;tbundonnteiu details. Yoti tua)'also vtaclt ailiiitioiml page s if txc�ssan'_
CONS• IA.•7'ION DrrAIL.S OF WFLL(Sl BRING ABANDONED SUBArrr rAt,tNSTgu4c. Toyi5
:tfLxh tirll cwrxrcruciiun rvcwrcltq+lj'u+4a11rstiFe ,F'rm+mrlti�rlr•ity',rttiuie uraxrra•a4nrr supple -
urllr O:VIY n 1r6 r'k•same*rmnbvrriun rahnralpra acK�L trra cyan suLmit Dire jWrrrc No. For All Wells• Subunit tIM fami tiithin 30 d;kVs of completion of well
fti«'ell map.
Se-21 abondotilucnl to the following;
Division of Waiter Resaurec�,Information Prirceari0g.Unit.
66:Total well depth: 25 (,ft.) 1 171►iail Senice Center,Ii:aleigh.NC 27699-1617
hell.Gor in 1ecllon In additii3lte to sending tli form to the address.lit.10a
fie.Rorclmle diantMcr.1 (o.) abo%v;aLw subauil one eopy of this form,tvilliin 30'days of caurpletiou of well
abondonn+eW in'11100llowin]:
.Division_of tiYntcrRcsaurces,[iuder•);ronnd Lija�cl[uu Conitvl Ptngrtenl,
(oll.Watcrlcvcl-bclrjq trrntlaid starfacc: (fG) 1636 Mail Scrvicc Ccntcr;Italcigh,INC 276994636
6j
6c.{tutor casing Icngth:(if lmown): (ff:) IOc.i nr Rater 51,- ..l•-.iuicrtlan Wel In addition to sending the fotnt to
the•address(es) above: also.sttbutit one copy of this.form tvilhin 30 days of
Completion of aril abarulontnent to the county hecalth departntent of the county
6f.Inner eming'ftubing length(if Iwown): (ft.)
ti•ltero abaaatioatctl, }
6g.Screen length(if luiown): A)
Fam GW-30 Naniitarotlm Deparinacat afEnvironmew and Natumt Rcsow•ccs—DhIslon of WatcrRcsotaca Revised Angu,4 20t_t
I •