Mecklenburg_Well Abandonment_20230905 (10)

WELL ABANDONMENT RECORD For tMenul Use ONLY:
Tltis foil uaftW
1.Weli.clintrac,tor]RlorMation: WELL ABANDONMENT fiETAII-K
Scott Hunt, Jr 7a.Number of Aj-el 4 being ulna"drjued..1
r vr*fly) For w1dople hVerifoir ar M) :srrlo wdLg. ONLY wah the some
S41'AH are Mil,
4561-A
7b.Approximate Volow' 't of Ival M, g fil
NC WIC11 ContridorC61fic;iUm Nittvbv
SAEDACCO FOR WATER-SUPPLY WELLS ONLY..
2.-Wol-ConStiuCtionPoLvtnit#1100000043,
7d.Ainauti t of&Infectaift tts<vl!-'
3.Wdl-use
Water SijppO WeJI: 76.Scaling M*Pials."Sw(dwo;Al thit apply):
b kwnL,C,1;lX1'WLIbfic 12 Nca i.Cefiletit. cot. 0 Beniton ite Chios or Pellets.
d 11csidential Watcr Sjjpp4- 13 sauw bill.wia Gniut 1YDty,Cb.v
ElbldnitrialtComnicrciA [JRcsidcnfialAVatcr Supply.(shared) 0 Cloticrete'Grout 13-Drill Cuttin
Grout b:Gravel
Non-ulattei supply Well-, .13 Beittoulto Slurry i 0 01119F(explain under 7�),
EIRCCO very
Tojcetion,wc1l: X'For each inatellial selected Am,proside awouprofmaterials used:
E1Aqtffc rRec1w,ii� 13GROlundivater R�nfi!diafion
.❑. . . I I a ❑. . - . - ... ' Neat Cem.:471b Wtr:3gal. Sand Cem.:lb Wtr:gal.
E3A. it, aml Rec-ovLk, Malihity Dander
C1Aquifc Test 0stornnOter-Drai4ar
E3E.xp;:rhEt6wl Techaolojv
7;.,,PruvidCa brill,docriptian of the abaddon-mcat lintcedure:
Mg.aeer
Tremie grouted from the bottom to ground surface.
8-1-23.
0 VELD
SE!'p 4 5 ?n73
Motiva North Terminal
radM;0ivh6r*6r_1C' 8.Ce.,niftailou"; InformaUun
rodlily IDAI C16pplic-,1610 _9(bra
DVV B.L
410-Tom Sadler Rd. Charlotte, NC 28214 i - 8/13/2023
PhysirdlAddless.Citv:wd tip 11101 r4llfrp.joy or%V01 0ivrier pale
Mecklenburg • I he-ebt,cei-fify,11w0he ire11f.51 was(were).ahavid-oned in
Ixvi.pruvided-f.d the*ed miwer
5b.14dindeand loniltukdn degeccsInAnutestseconds o
(91VOI ricklou tie-6004d-ji 9.Site diagram or ad(ftdonalvveif&tatls:
You'alay.Use tlkback:ofthis Ng�1q'pr6vidi additional liell site'.decjils%orwill
C.0NqTRitCTl0M,DF-T.411S OF%VELUS HEING ABAN DON19D. SUBN.IITTAT,INSTRUC.TrON
,Wvdi w-;e11.ewjzvLqtt&jtj nimulli)
li,qb,oxiv Ilk)rlm some IOU Cal;sirblidt ofte M Igo. For All-%Vd6- Subiriil lhis'�forttruithin'30 dikVs of c6tuplc.tion of mi-ell,
.0-
6q.WqU 1:6#;AS-12 tw roljow,ing;
DI-Visina of
610.-Total well depth: 10 —A) 1617 5(Ail'Snhore Centefr,,RAleigh,NC 27699-1617
IfJb.6r Itilmlon Wells; In bddhi6n-to seadiogilva forni.to thli addiess in 10a
6C.-Bollikole:dianieter.2 above,ik[SP subodl one copy of!his Vona withitil 10doys of coMptelion of well-
abiridounnent to Giving-,
Gee.Water leveltelowi ground surfatei 5 D[vlsion of !kMud hijelci an 1636 afail.�Cn'icc n 94 Conifi)l Pragral:11,
Center,Raleigh,NC 2769 636
loc. 111fecti.�n AN"011%.- In addition to sending fliefomilo-
6c.Onter ca.sing length(if linown): the address(esi above-'also submit.one copy of this foint Within. 30 days of
Completion-ofivell abaldainheni;to the conrily lwaltk department af-lbe county
�vhcm abandoned,
6f.funer easingltnbiug length(K lmoWn).-
6g.SaMi ldrigth(if knoll,4):
cw' limes Aagog 2013

I !
WELL ABAItiiD.0N14IENT RECORD For lmiiml U!c Ony:.
Ttiis-foam can lie used foe single of tttuitipie}Valli'
A.WCH-Cnntractor 11.09 mation: W LGARANDMINTENT DET41L.S
Scott Bunt, Jr a, timber ivella heingaliundl ned' 1
7 Y aif. � o
IYCDL.CGdt3Llgrl Oh'(OC1`aLL05sACfpC[SdIL7lLy:alvrynfaning\tilL10n11191i1tPpiUpCfly1 For 'mlrlople olferucir ru• rilraaitirtar• s1rPlth. salts ONLY Willi 11W sarue
'' • -iy7llrbrrCrka'r%l�t�NiIL�?AD1�7dt:,lY.1y C}Nr S,d�'JWN�LVrRfOr71I,"
4561-A I •.
NC-Well CvnlrJctorCei110icaLiotr NiiuiFicT 1h.Anpniximxtc t4rluine of«nc�r i emcrug in ti ell(v}i (gal)
fl
SAEDACCO FOR WATFiKSUPPLY NVE.G>z,S iDNLY:-
Con>purn Naruc
7c Type ii[di.�iafiYtatit uscil:
2:.WA Constiuctiou Permit#,100000043
I.t3tirJirrpp>ltarbleurlJ}wrmtlr(I.r.�rrrr�,Sruli�,i'nrrluK•'e,lnjerliol;art:)�.Geuwrr
7d,9ttwunt of-dislnfectsidl Neil
3,b�+rjl u�r(ch-ect�irell u�ejn ��
Water Suppl.Wcll: 7c.5caliog:tnatcti:tlsrased(cltcct;'ail#list apply);
OAgriciii(itr91 Glivilitnicipu . . o 13cntonitc Chips or Pllets
1 , n$ CntCYut ] )O�Sothcmat(FcatiueXoolin Supply) ❑tcidenda Vatcr Spp -,,(singlg) ty-ct}ci
t7indnstriollrgcimnterciai t 311 0denual�Vatcr Supply,(si itred). ❑CI Coticte(ddrout DriiI
e ;CLltiti s
❑irti tiou `13'Specia[t}Giuut D:Gravel
Noa'-WatcrSuppty�Vclt; 13BetYiatute'51utt}' j Cl otwr"(explaifl.undci v.
�Nlmiltorine ❑Rccdven I• .
I'njcction NVcli: X For each titaterial selected OHM,Oroside amounrof maiterials used:
I.
❑Aquifer Recharge l7Groumhealer k6awdiation
Neat Cem.:471b ,Wtr:3ga1. Sand Cem.:lb ,Wtr:gal.
OAquifer$lonigean;[E2Crc»�eiy. ��ultitily'tiarr'ier :.
❑Aquif&Tesi ❑Slomnt'aterU'niin ge: �' '
17E�petititett[st1 Tc lfnnlu�ir �SuUsid �:Cotitml 7 .Prm irlc"a.hricf.d6criptian of,thc abihidonmimt proamlun:
MbcP hemutl,(C(oscd Loop) MTracer
Tremie grouted from'the bottom to ground'.surface.
C7Geothetntal(He:ttiu 'CoolinaBettirit) - . ®Qtltcr:(thplaitiunder7 )
�.'Aa"tGsvcil[s).aBlanilranctP: 8-1-23 tp'%"�i ,P L:i V C L
$a.Well locyiion: S E F 5 2023
Motiva North Terminal ai
$.CertiRitioit: tnrrt,,z.!C tl?r•:;:���. Urk
['utilitp,r]i�irer3$rvrac FaeilitVIDN(irupplicalilcl D�ivC�r'R:Zi?
i .:
410 Tom Sadler Rd. Charlotte, NC 28214 8/13/2023
Physical'Address.Citti:grid Zip ;Sikwflife G).di 44,{V41 Gaut q clol or Wtn Qivwr 13.i e
Mecklenburg Ifj:.vaynfn?,thls fnlmr, I hereby,ecj'tify•11rat the we11t's)was(irere).afiandoned hr
C6rusil' Parrcl ldcrult'c tinnNo.tPt�Tj accVn1a)rc0 will l.�il h•GtC.02i ;0100-or 2C.6200'Rrell CoriS'lrucliurt'Slanikrrds
aniflkal ciiopYOfAhis reeorellrt SheerrQrnviticrlld.11waiell otrner.:
5b.I ttititdeand longituftIn.dcfiriscsrrh_initceslsecotidsnr.d+ccim,AI ftrecs; 1. .
(ifn till C&1 o�rc:4iiltnit piJ(ic ical) 9.Site diagrain or additional vtell,details:
YOU.nta� use the ba&of dins page to'pr&i&*addition;M tall site.&bils.or well
r? �V •a bandonnienf retails: You tuay a6 shack 64diii0'w('pa'ge94f necessacV_
CUhSCRit(_-flQ'X OFTAIRS QV WELLfS)HEN(.-AHANUC)NE'D SUBAfFi'P L iNS_TRITCTrUVS
ttrr:eh urA c�risrruttrtn rLMF'1rs)I �voil�Fe .F'ur mithlfile ii jeaidn rir Mil-11-urir supple
rlells:OVLY n_t®i a're semacnlrslirnrabrduLivrrlbl:rrieru.��a can vd!m1t unr farm, 10;t, Kai.All ♦VeILs: Submit flik fomr xiTttiin 30 days of coinplction of well
`Nell[6g.-AS-13. abandotimeni to the Tollotving:
Division of Water Rebnurc►s jnfutm ttitin Pruceming.Unit,
ALii'_4Lnicc C'cntcr Ralcigli.:NC 276994617
6h:Totalwell depth: 9 {ft.
10b.Tor Tnlectlan Welts: In addltiou to sending dwfgrrn to thi address In t0a
Gc,Botrkoledhtnietcre 2 ltu,y :drove;also'subuut•one.cupy or this fortu willrig-30'ft%of coarpleiitrtt'of%VeIf
nbundoumeut In ttie,follotvin :
C 5 f DhisionafWit&Res anrces,[iuder ruunilInjeii6nCorit"Pi rdgram, .
tt1.AVatcr ICFcI.bcicr 'ground sttrtacc.. (-r) 1636.Mail Service Q cretCi,itAlcikli,`k'27699406
10c,Far MIV Sunnh :Cr TnicW n!R'eI : Jn addition to sending the font to
Ge.Outer ca.ung length(f i rwwii): 4fW the addtess(esi above- also submit.brie cppy of iW.fotni Within 30 'days.of
comptetiati of ipcll ahartdmrrirent to itie eaunt}' heltlt6 deparimerct of-die eormty
6E lhtnee casin;Jtetltint;Cen},K�(if latnvr%n): (ft)
tvhcrc abatalot d,
6g.Scr i n lent tIi if known).:
: (tt.
Faim W-30 N01113"6tutlm Detnruucoi ofErrOronmentand MdumtReson.ccs—Dh•idanof Witel-Rdowws Revived A#Lwu 26B