Mecklenburg_Well Abandonment_20230905 (6)

WELL ABANDONMENT RECORD � Fat lMdnwi Usc ONLY: �
This feint cafe lie used fot'single pr mullipie rreM'
I.WcEt:CriudilctorltforrnAtilru; WELL ABANU(11\M1TEIVT DETAILS
Scott Hunt, Jr 7a.Number ofne!ls being altando'ned: 1
ltirClkCputri�y0th (Of wa onw'-wa, liatly'ilaamtflritngttatlonl�fsll>irprupcnY) Forrfnrfrrpfe' lgerttoir to; tvjlwllriw sypjkq�•' �'W. 01'LY wNL 11.+e save
craerrrreUiuuirl�mtdrrnni��V;rerr+cmr sr+twin arejerrn.
4561-A
NC Wcll ConiracdorCenificiMon Nitijbv 7b•Alrlla�uimate rnlunre of tF ltf(rein riniug in Aicll(sji (• 1)
SAEDACCo FOR AVATER S[l['PI,I'Wfi US}ONLY
Cohtpan+Nanrc 7e.Tyne iif disinfectant uscil: I
2:Wel!Construction Permit 11:100000043, ,
I mid'rtnpflt,76le ue/l/mrmidv.ri.e.t w'do.,Stdi'.Yu cat.)lJllttuwrr'
- 7d:Amount oGdlsinfectutit used:
3r�Ye1t usa(cliecl:hell u tc}:
Water Supply We!!: 7c:Scaling titatcoii:tls tisctl(sheet:ail fttat amply):
C]Agrictii(ural C]R4unicilxrl/Pn6tic: lA Nat Ccntetrt.Grtiut i M Her,tonitcCltipsofMicts•
di3collicmuit(Hcatipj#C-ooltnb Supply) l7R sidcntiat`Vatcr Supply-(single} >a'Sand Centeitt Ctuut ❑ 17ry'CL1y
❑h disitrwWcomntcrOil ❑Rasirletniat tVAtcr Supply triharcd) ❑ Grincrrtc Grout ❑Drill.d71l1in�s'
❑Irri tion ❑Sloec%oity Grout t7,Gravel
Non-WIter'S.upoly Well; ©Bentonite Slulay ❑ Qiiter texplaitt utidec 7g),
Elimalittorhie: ❑ltecoven
injccti0n NVetl• 7f.Foe eAch titaterial selected aljoFe,protnde awount of littiterials used:
❑AgiuferRecbaQe. ®GniumlitaieaRcnttduition Neat Cem.:471b ,Wtr•3ga1: Sand Cem. lb .,Wtr gal.
❑Atltlifer Sloritge rttxl 12�Y�a1'rry ❑sawaiv Ranier,
I
❑Aiiu1keTest ❑Slorrmt ter.l7rstnnge.
DEiperiteteulal.Taeltunlogv ❑Subside Cofdrul la.Piitvide a brief.discrtptian of-the rb tndnument Procedure:
13(3coiltentrtl(C€osed.Loop) OTMcer
Tremie grouted from the bottom to ground.surface.
®Geothetmal�(H�tiu>ii`GoolinaR.etutn) - - Gl�tltcr.(exalainugder7gy- .
r
a:Datc- cIRS)-abandoned: 8-1-23
a
SiL Nell lueatitio:
Motiva North Terminal 5
Fatr7iljarhvixrNmrrc Fa:ilitrlD�tifipplicabisl $•Certifii:sliou: � s ��• �,�•����
410 Tom Sadler Rd. Charlotte, NC 28214 i�v ` 8/13/2023
Pitysical"Addrem,City,acid Zip Siyzylnsuof Ccriifia+tWell Cquimclax ur%Veal&iVwr U:ite
Mecklenburg Ify-sd$1ting.lh?s•Torn, I trerrbv cei'fif trod lJre tirell(sl ri ns(here)rihrurrloned in
Couuly Nrcel ldentifc rilnuNo.(PN) nc-i'vr rlewvc wth'ISA'4uk O e^ 1(0 or X 620o.rme11(virs'fntcliurr Stnruk,+ds
xrnilllrat ncnpy�fUiisrscarrl7rusbccio.proviilsd•fa7lrcH•ell rns•�rer.•
5b.J.atitntieantl lmtgituif+„in d�cstminpteslscinnds bi•rliarittuil degrccsi i,
(Y,3c11tatA,<rra:4ir11t,lrg ita7rJtictetz} 9.SIN diigraut or addidonatwell details:
Ypu aia}•'use.Ili!back•of dais page•to prov�ide,,addi iotial iivft sitg.clebils or Shell
1t �Y ::tbttudoi»uznt tleiatls, You tna}�also::ulttClt additioltal pao s if ttccc•ssas�_
[CdNSTRIIL"10M DE TAILS OF WELt.&I BRiNG AB.L-ywwED Si UNtrF.TAi:iN'STRUCTiO S'
.trlrtdr tirll roizrrrlrtllurt ri�vr�tlel 1,j`n�iv7lriri:e...Fru••trrulli�le.tii��[tiait rir retin.nxtriysu}t�h
ue1le,DeVLY nlfJi tlk,sarlre cr rr+irrrrrrtaNrihnrreloi:mcrar.l v con sriLrrrli air frJnrr. Ifla: For.All AVellc• -Submit i6 form a ithin'30 days of completion of=ll_
6i.NVcll[1€l•AS-3 �btindanrticnt tQ tttQ 1o11otving:
MASina of)►5ttcr Hesrilttr�,Infgtinititiu Prriec3.4ft Unit,
1617 Alai)Scrndce Centci,Italcigji NC 2 7 69 9-1617
6ti:�'otal frill depth; 36 (ft.)
f9b.f or Inlcclisn Wells: bt addItitiu to seadiug Ilie fbtnt to the alsitrss fa.iOa
fc:Borekale diantctcri 2 (u.} above;also suf?ttdl one topy of liis;fcinn witlin 30 days of completion of Well
Abiindolutteut to tlic.falldiviny:
Utl.ltratcr iL cl:bctos�stotttid surfacoe 19 Ift,)
Dhision of%tci•Resources;Uuders lti►ttuil brijectlon Conte]Fr6gram,
l63t Mail:Service denier,Ralcigh.Aid;:276994636
Ge.Outer casing length(if laver n)• eft.) loc.F'nr Wadi•:jiMIjl j j inj fr�fnto�Veiic; Ili addition to sending lbe fotlu(o;
the'Addiess(e$) aliose.'also submii.bus Copy of this.fomt within 30 'days of
completion of well abandownrne cp ibe county lwlaIlk departmestt cf the county
6C Inner casinWtubiny twtah(if latau`n): [ft.) i0wrc ibandoncd;
tin Serena length(if known)-Q.
Foml G%V-30 Nonli Ca ctlm Depanmerrl of Envimuntent mud Natwal Rcsomecs-Dlvisianof Water IRdioum:s Revised Aigvs 2611,
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