Mecklenburg_Well Abandonment_20230905 (5)

WELL ABANDONMENT RECORD k �
For lu7crtuta vw ONLY;.
Tbisfuimeaulie used foi:sika ertnuhipletFglls'
I.WcE1 Contractor lnforrnution: WELL ABANDONMENT DETAILS
Scott Hunt, Jr 7u Nwnitcrift�-�•1L4i1eenl;uiro jd lned: 1
Neff. ntytaiiorlr°anu artiellotstrcr'�tsotM altaati� +tetin>!ltCslLcr ro n for .nnrlrtple rryerrrar or rv�rl-Wdrer snpp•}' bde& AVLY wills dw- sraW.
S R Y p' �} c�rasmrenbvr:iahmrctrmnierrt►vvtrorrs'J'hrwwrafarm;
4561-A
NC.�Vell Coatradorta ifiaitiou Nituthcr 7b.Aplrrnsinrate t5ilttnte of fiat m ins;in itiell(n):
SAEDACCO FOR Wr T.E-R-,UPPi Y%VEL)<�:S"OnY:,
Conk utr Naruc 7c,1�jie 6f dasiufectarrt used: i.
2:•Well"C6nsttuction Permit#.-100000043,
Iiurdluppkcblei��tltarmiir.(I.N:CaWry},Stu.,larr�,Ye.I,jrrrr�; ra[;tlR.�,wq 7dc_Luountof'dlalnfxtsttitu �il:
3.W�1 u�(elrccl:lr'i•11 uacj: � .
Water Sirppl•Y 1�'1'cll: o.se�hrrs►natcr�als used(ehcc 'au ihat apniy):
17, Fiict)IhtA►f 17144ttnic p ttliT'tibFic_ lil3 Neat C'etnctit.Gttattt M-Bcnlonite Grips or Pellets
I3_0c91hcrml(Hcating/.'ooling Supply) i7liev.dentutt Water Supple 6ineg1g) q Saud Cent ut Grout ❑ Oiy'CL1y "
Elw1 striallc6tuni icial ❑RcsidetaialAVtuer Supply.(shAmd) 17 Cotlm&Gtout I ❑!)rill 6ttio."
❑ins dov SpecioEt} Giout -Gravel
Ron--lYatcr StipPty�yeFF; P Bentoeite Slutap CJ Oilier(explain under 7g),
[&Itiloriltoririe - ❑Rt�n�•rn, '
injccttion Well: XFor.each tnaterial selouted above,proFlde ar unk:of materials used:
❑elijulferEtCc6aiQe ❑Giauitdituter-Itenledi:ltian Neat Cem.:471b ,Wtr•3ga1. Sand Cem.•lb ,Wtr:gal.
134tiulfer Stisitige:uxi tter6N'Liy [iSitliuity Barrier i
[]AiptlferTesi ❑Stonmvatt rD'ririna�e
bkxpgrhft6a.al.TecIntologv ❑Stibsld a Coritctil 7g.Pi6vide a helcf description of.tW abaudnnrrrcnt p"wedure:
MGjec hermal.(Ciosed.Loop), OTracer
Tremie 'grouted from thel• l;ottom to ground surface.
Mcodwrntat(HCaliuF/CoolinR Return) ®Oti►er.(es lain under 7g) i
t.Dato el!(s).al►andrined: 8-1-23 I'd 1VED .
Sa.}Yell wn'tion:
SEP 4 5 073
Motiva North Terminal
$.(ertllllarfl011: lrltCiitw'+:'^l�r, ^,r a�
FaC7itj•+'On•iicrNuinc lDtlGfippliwblca � •��. a Ur>;i:
410 Tom Sadler Rd. Charlotte, N6. 28214 8/13/2023
Pli}sisal Adtlms,City,-aid Zip powl'O5 MstilI20 Well Cwartclor.or 1Vel1 QlYrr:r Date
Mecklenburg Iij+,siErririg:lhls.form, I lrernbt+.r i�rNfV lhnt the a e11tSJ was(trerej rrl�imdared in
Couuly Nree adcal3fkWou No.(PiN) Gc atrlrnrce lriii,I S a?�C;-tC UZC,�a100 U,2C.6200 IrQ[C0iiSlialcliofl'Slc wkirt(s
' nrrilllrrria€•np}�G7•�'II7iSr'CCOr[?'Jr4�SbecriprnviilerL•follte-rvellrntirer.•
511,i,�tit[iiie and Mngittrcfc.in.tt�ises(minirtcalsccmit>r of dcsirnal.rtt��t;rrc.5:
(ifri t n fa tp,irw 6lthaug ics trii Bctx) 9.Site diitgrain or addltlonal weil detalls•
Yau ivay tt;e tla.it"ac);'oF'd�is pagr;io pro��idz;:tddihaiial idyll site.dettiils orn�l]
A' �Y :abatxlottirizitt iietails.. You may aisn,:ivacli arliiiGuual pagt:s if rtecr.:ssaty_` ..
CONS C1ZtlL"'I'IOM DIETAUS. OF WELU.'S6 HLi1N[:AH;1:NbONED. sl1HNiE7'PAr.iNS_ UCTF0 .
AtN6 v:r1J,.roarrryriiun rrcvril{s�1 f fli illtililc . FoF'mulvj:le inlpcfidu sir rwn•rruiu•wy h
eelts•O:VLYrriihrl .av+ne�icibrarrev:drilidinloiv:i re►.,ivucYursi�L:rerr�,irrjunrL. 1044 Far-All Wells: Subunt thm fonu:uithin'30 dp s.of couiplc6an of tnell.
aban4lontncnt to tits fniln�yin .
DiVisitni of�Yuter Rtxiiutrts,dnformutiiin Prryc in .Qnit.
6b;'Tatal well dcpol: 20 (ft.
1G17 Mail Suffice Center,Ralt:iA.W 27699-1617-
I.
1tlh. nr Inleclion Wells: In additiiiu-to sending g pa'.1brnt to lire addtass Ia.10a
fc. orchalc.dLtntetet;2 Oa t,nlsd subndii one eopy of ibis•fond Within•3b•dmys.of eoinpletiou of tell
xbatidotunut 16 tlte•fa1161ving:
Divisloti afYYmter Rcsour cesj Uud ftround LijMIo_n Control Pr6grau,
6d.Water lc;cl.beltity grotrrid sttrfateo: 10 (ft;) 1:634 111rrii"ice Cenicr;'Ra1ci h,RC-2769-1636
loc.Ror Water•5+mniy is"'Latll W 1.1Is: hl addition to sending the forte to
6c.Outer caung knp*(if iaion-n): #0 the address(esj above. also submit oue q:dpy of_this foini Within 30 days of•
coropteliou of-ivdt abandournent t iIhc county health del mintent of-the wunty
6L Inner casin�„�tuhing tength(if anrul�`a)q (ft.
ii<bertc abdndoncd;
i
i
614.Scriko length(if knotva): (ft.)
Form G111-30 Nonli f'arolitn Deporinxm al'Enrimampt and Natural Resomecs-Dh•isloa flf Waterltes otirms Revised Attgusr 2613

I '
WELL ABANDONMENT RECORD For to nmi ttsc t]my:._
Tliis iboRnrah Ue used foi Mi(•e4e of multipkwells' f
1,wClI.Contr:ict'#]nformatidn: 3NELL ARANDONNIENT nE9°AIIJ5
Scott Hunt, Jr 7nL Number of being ahall dqued:.1
's��etf('ULYfaCtOl l�.1nM(6f iil'.11d5t'nCi pC.ISOr1a11x;a13atLi0nln$uoll.on9�s11rcr tiruperry) For rrmlUple ,n1ptlimi w• ri k1) 'iia S1rlift, was ONLY wldl the stove.
C'�h1YrTPrCtJ(Hr%lrjN'11rCirATRr�7Jf,Y1N Civ?Sl Mot ivrefrrm
4561-A 1{I
NC n'cl1 ConlractorCepiftGition lYuimbct ?U.AltprnsinratC vnlpree of sfahTi rem iilning in
SAEDACCO FOR WATER SUPPLY NVEFA•S ONLY:
Cdnvan±atianrc
7c,Type of disinfrcfarit ur..crL•. i.
2..Well'C6nstluction-Permit#:100000043, '•
I13t�e11 e)iph Ld¢urll FcrmPtY(i:e.Cnurtfy,Smte;1 Ur1lar cr_lirjsrtiui�,ert:),ijRrmwn 7d:ArriOuut of disinfect"t use
3.Well aye(4*e&wenrelie):
Water Supphr WeII; 7c Seafitig;tnatcrittls u l-(elf t:all-iltat apply):
C]A.nrknitiital' I]hlimiCip:'rllPubtic. r�TlcaiC"eni¢i;t.Gcairt , ❑ 13cniaoifeCfimsor"['cllets'
00eothcrmal(Hc.1"4/C'oolino Suppty) ❑Rcsidentitil watcr supply'(sin&lg} t1'Saud Ci ni W:Gtr ue ❑I)ty:CLay
❑Iiulaslrtat/Comitcrcial ❑ResidttuialVater Supply(sl m-d), .❑-Cdncretc'Grout ❑Drill.0 itUigg,'s
❑ini tiou 0 Speciatty�Grout 0:'Gravel
Noa Wptcr suppJp�V'clE: 0-Beiotonite 5iutry ® Oihei(explain under 76
[&hlaiiiioeiag. l7Reerisen �
injection Nvclt: X For.-each matetial scl_ected above,pros'ideatnounrof materials awed:
❑AquifcrltCcbarSe ❑CjniWsd}y.ilesRe»tediatiair Neat Cem.:471b ;Wtr:3ga"1. Sand Cem.:lb ,Wtr:gal.
[7r�tluiferStonr�e,ancl Retb4'eiv t]Suliitity Barrier
DAgnifcrTcsi ❑Slornnsi�terlJ'nti-nage .
DE�cperimeutal Tec ltuo[oev ❑SuUsldeixti Catitml - (, ,
7g.Provide u brief.description of the rl►andnnment prrrccdum:
13Gucodiennal(Closed.Loopy MTtacef
Tremie grouted from thI' bottom to ground surface.
®Gcolkenwi(Ne<ttiuw'Coo1h) Retain) ®Other(csxtl.•iin under 7r,)
I ;
� pate scclt�s):ahandoricst: 8-1-23
5*Wen lucaiioo:
Motiva North Terminal
Fuci]itj'rt7urincrNnirx Fa:i1t IDf1(ilfaDPlicatilc) S.Cesftlli.6tiQti: Iih`Crow4icli'�f•.
Gi���lt�nv
410. Tom Sadler Rd. Charlotte,-NC 28214 8/13/2023
Physical Addmss,Cfty rand Zip 5i first of C sti(ity!SVctt ilnlr rclai Ue%VCfl 47?rrrr Dii7e
Mecklenburg Bit stnin;3.th&Jarrrr, 17rerrh}cei-d JJlat t/re xve11(sl,s+ns(rrerej rrLandoijerl in
Cnurity nS74tc11ofr SCcrrrikitcls
rriri171rrr1 a npjcfelrisreeurrll s becvr:provitfcr!tq Aru.well rnrirer,.:'
5b.LaWrideand lonowde.Ini itegrecslnr€notes/sectiiiclsord6cinial.degrccs:
(itty C)t t�;td,o�N:liitllntrg tsay�tt,cxui) 9.Site diagram or additionat well•dctatrs:
tipu.iva�"Atse il�e-b' k of this pan to'ptoviJr addition it We0 site.de6ils or win
' V :aba-udoiunzttitfeeailss You ivay•also attach aclditiuual'paes if rreci'ss:try_
CUNAiRitCTION DETAILS OF WFLL(Sl tiOW-.AHAN60NED. �
,SITRAi]TT;;i,iiNSTR[Tf:'i'it?ATS'''
dltuela.u�r11.rriiistrirtriurr rrinriJ(sJ IJ'ui4alltirila .F�r'multiiile iirf�rlirui Gr•rxln.nvr�au}rph' .
u�ila ONLY with tJr�sriinc erucstrxfronfal ivrgiforrtrlcrlt.;i�u cma s4rL{rrft iwre fans 10;t; Fnr.Al %Vtgs: Submit 1lu.5 fora iiiti in 30 deli$ of coniplCtion or.tsell.
Ga.Well m aAS-5 . abandonment tii*following
Ilt000u of%'alcfA01uraL%S]nformAti in Prvices tEa .knit,
Raleigh.
1:G11 Mail Seisice Ccnter, li A 276994617.
Gb:�'atat ncll depth: 17 (ft. S: � .0
tOb.Por Ittieetfott Wells: In additiou-lo sending the fornf to the address-iu 10a
Gc:l3orchaledLuiieter:2 ('tu.} akgye;Asn`subuiit one&py�of this forui witltiit 3044ys of cotnpretipu of well
abHndoomcid to tlia..fa13ds1'Q: I
(qp Water W 41'.hclosi'ground ciivfaec� 10 (ft;) Divislomof%terItesourtcesi Lindergroupd•BtiJ&-flonrConerol Pnagranr,
tG3ti.Mail Scztice Ccnt&,Raleigh;Xti 27G99 J636
10c.Fnr3Valgr @nnnls-&]urcctton <<ella; In add
Ge.Outer casing length(if Imorrri): A) ition to sending the fomi.to
Me.address(esj above. also subarit,666 copy of,this`fbtnt Within 30 daYs-of
completion of w-eli abandmnnsnt to the county hcat1h deparimerrt of It.county
6f.Inner easinWtirhing.tengtir(if IniaWn): (ft) tVwrn aG mdoncd;
6g.Screen length(if kuoisa): 00
Forst G%V 10 Rautli Carollm Departmcui of Enrlinnrnent and Natrrrat Aesuugces-Division of PlaterR I oiures Revised August 2613