Mecklenburg_Well Abandonment_20230912

WELL ABANDONMENT RECORD FbiIMCraayscony;
This forth can be used for skeale or multiple hells
1•Well C4utractorinrorvration: WELL ABANDONMENT DDETAIILS
Zach Thompson 7:L Nutnher of hells briny;abandohed: 1
lVeltCaumcyotiramtetary5¢Llo,�rrrperwnallluLismkiwm.�5e61.onhigIlrcrprepcny) Fcv rerriinple- trtfarrtar ar rera-StYiter srrppdr wells ONLY wtrfl rr:v sarrc•
c•Ort frrrcGvrViltrarPrfYAlulerlt;}ern c's�vr r;drrrbf L riruG
4478-A
NC Wall CcP.IraUur Curt 1fic,i1ion III nib cr 7b.Appniiximate viilume of SFyfiT'remaining in vvell(s)i {gal)
SAEDACCO FOR 1VATF,R SUPPLY WEL"DIMLY: - - -
Company Namc 7e.Type of disinfectant Ined:
2.Well Construction Permit#:70003022, ,WM031210
I.ur�rll nliplrrrblc lr,�npzrarrr l.r-tw,..rr,Stir,d iurruYx firfrc;��n,,err.};fvrrawrr
7d.Amount pf disinfedf nt used:
Water Supply Well: 76.Sealing Inatetials used(cliccl;a1101 at apple):
17.4,gricultnril ph9ttnicipctir7'ttl?tltc DINcatCcnitnt.Grout 0&cmtooiteC:hip;or Pellets
❑C=.thcroiat(Hcatirkg(C4olina Suppty) i 1Rc5idenri,•d XVWcr Supph•(,inglc) ❑Sahel Cente*Grout ❑Dry Clav
❑h4ustri3 lcomnicrcial ❑Re ideotiat 1Vatl:r Supply'(shared) ❑.C6mr fete Grou.I ❑Drill Cittiings
❑H •tion ❑Spf-ialty Grout ❑Gravel
Non 1Vatex'Rupply Wc11: 0 Bentonite slung ❑Other te\piain under 79)
®141onitorvie ❑Recov'ery
injection Well: 7r,For each tuiterial selected above,provide amount of materials wed:
❑Aqurfer.Rechar96 ❑'Griitriidaaterk6kdiation Neat Cem.:471b ,Wtr:3gal. Sand Cem.:lb ,Wtr:gal.
l7 lqurfer Seoriige;ttxl Rrcov'en' ❑Salinity 13an'ier
❑Aquifer Test l7StomrSvater Drainaei;
.0Eapennirteidal Teclntoloty ❑Subsideix c Coisttvl
7g.Pruv'itte a ln'ief descriptiuu nf'the ailandnoment pnre+dun
C1Geothennal(Closed Loop) OTracer I
❑Geothermal(HfttiDO'Coolin2Return) OOther(xx lainunder7 ) Grout gravity fed through tremie from the bottom up.
i" ..
4.Dattwell(s)abandoned: 8/22/2023 `— K..r
51L Well(o¢aturu:
Abernethy Lofts Irtf�rilaase,'t 'r;: �r,� l�r,
racrlit?-i0wrxrNumc ra:ility InA(rappli ablc) $.Ctrtllir�tioD: drat J,O:
3934 Raleigh St. Charlotte, NC_28206 �CG /iGBO�B!?i 8/22/2023
Plt}'swal'Address.Ci1r;altd Zip aiglnri:(it C2rtir*d Wei coIIIr 4[(If Or 5e7 oluvve Df4
Mecklenburc !3y'sigrrittg this fGrrrri, 1 drereby r ertifi fh ri the a elljcJ m cts(ir er�)ahandoned in
Cowun' Parcel 1&1111561101040.(PINj acre rrlrrircc u�rfir is f VCCIC 02C•0100.crr 2C.0200 li t11[turs7rrtelitrn SlsrrtrJrartls
and 11faf a copj,ofllris record has•been provided ln'dhe'well aunc'r•
5h,iatifudeand long7trxdc3n dcgiIrtiinutcslsccnndsordixlte,ill degrcc5:
(Ire,cu r441,fer4 Rlril r4�'ic i71r3i xr�} 9.Site diagram or additional well details:
35.150741521 -80.474785856 You,niay use the back of this page to provide additional ivell site details or well
W abaudoiunerttdecails. You tnap also altaeltaclditioval paa s ii riecessarv_
Ct4NSTRlI LMON DETAILS(lIr R'ELL(S)SEiNC ABANnONED SfIRRif PI Ai.iNSTRiiCTrONSI
Affil fr 5rr/d eva lryrritlrt nevrelFs!1�•mryharik- -d'r r mufGplr a cfiva ur ior+r-rixrtar�Lppb
a•efdr ONLY v-irfi Aw snuIccvrc,uacdmr aarrthurr!tch:t i�ur cvn arLaert curelirrrtt 10a:Nmr All Wc[Lr Submit 113Es form within 30&a}s of completion of urll
62.Well ID#•Mw-i abtindonnicnt to the following:
DI►'islom of Water Resourem,dnrormation Procvssing Unit,
6b.Total well depth. 33 (n� I611 Lltail"ice Center,Raleigh NC 27G1YJ-1617
lob.E r Injge Wells: In addition to sending,the form to the addtess in.1 a
Gc Ilomhole diameter:2 �D•) abort;-also subndt one.topi Of lbh'form within 30 days Of coingitetioa df i5 11
ab eodomrtertt to the iollmwilis_ I
COL.Witcr WWI below Land surface: 22 (#t) DiASiort of WaWrResourecs;Underrgmuitd Irijectloa Control Prdgriun,
I63611fail"ice Center,Raleigh,N(J 27G99-1636
Ge [litter Basing lengffirflmnvsn - 10c For Water Srrnnh.4c inlectiari tiYrll?: In addition to schdin the form to
- tare address(es),aboi'e, also Subn)'it.,oiie'copy of this form vvithiu'3U days of
coMptedun of url1 abandonment[D`the county health depaiintcut of tho courtly,
6f.Inner eusinWtub6jg tent'-tlt(if h-ngt vn): 23 (ft) vvl;ciG a ndoned'•
i
6g.Su va length(if Iwo-n n):10
l
F6rra G1v-3ti - North CaroGtn Ikpanru=od arEnS•iroamcnt atYi N;ntirat P,esuurccs-I115•isioa of lVatcr iC,soarRs Revised AKpsa 20 B