Mecklenburg_Well Abandonment_20230912 (2)

WELL ABANDONMENT RECORD FQT MUM] sWanY. ,
W.s b.hncanbeusedforskgfe•ormu10ptel%•ells
1.Well Contractor information: WELL ABANDONMENT DETAILS
Zach Thompson IL Number of"Clis being ahau'Ld: 1
wl!31'C1DrAMa07N3iIt6 W%Vi 11351'ri7 jk'[5{IfL7ny:1113njaj lne w2m bit IILSilrrprupcny) Fcv widaple. 111,IL•tfwr ar tkin-litVcr ;supph, wells ONLY vrdh Mw swne
caisRrroflat,i�'rn�rclrr,un��raf,}raw c�ve•riryjUt rxrefrirrn.
4478-A i
NC 1Ycll Cnntrlidvr Chit it"rallion NmrbcT 71P.1-Aplrrni mite snlnine of sirilfi -'reinaiuing in q•ell(s): ( )
is
SAEDACCO FOR WATFik SUPPLY WELLS ONLY: — - - --
Cctn�,an}Namc 7e,XApe of disinfie&jnt used:
2.'1rVcll Construction Permit 4:7ot)03022, ,WM031210
I.iu yJl nipfh?rblc riei!pNxmfLr(i.a C'wertn,State.J urrurxr,lilrc�iorr„Ndc:)Pfterursra
7d.Amount of disinfeetsint used:
— - — - -_.
3.Wdl u+r(ched:still usef: - -- -- - - -- - -
water Supply Well; r G Scaling n>waterilc'uscd(ctaac all That apply);
i7 agri�tltnT91 17h ituiicilztttPttlhli y 51 N=Cement Gam i7 IJcwodile chips or Pellets
❑C wIlrcrmal(HcatiAWC;cling Supply) f]Rrsidr:nti,•d 14'ater S�iliFly'Csin�lc) ❑SarvJ Ccntcyel Gmut ElDry Cl
z v
❑IndustriallComntorcial ❑Residential Wwrr Supply(shared) ❑ Concteto Gnsut ❑Drill Cuttings
❑lrtig tion ❑ Spc zahy Grout
❑Gra%'rl
Non-A.Vatcr.5.ppl.•Well; Llentofifte Slurry ❑ Other(explain under 7g)
MMnniloririe ❑Recotiery
ttijcrtion Well: 7f.For each 1111te_rial selected above,pro%•ide atn0llot of.materials rased:
❑AquifcrRenharge OGruuiiditdlcrR*edimion Neat Cem.:471b ,Wtr:3gal. Sand Cem.:lb ,Wtr:gal.
DAquifer Storage aial R COVL" OSadiniii•Harrier
❑.a niter Test
9 ❑Stounn%titer I)'raim8c
OEt•}ierirteiiielTeCllrtCaliig_ti ❑Subsidetx:CCdiia'1m1 �
9g Provide a brief description oh(te abandonment procedure:
00colhennal(CFosed Loop) t7Tracer
0690(hemial(iieijtlin 'CooliDgRettam) 00thcr(eti lainunder7g) Grout gravity fed through tremie from the bottom up.
d.Date well(s)abandoned: 8/22/2023
Via,Well lueation: C P 202
Abernethy Lofts C
F¢ciln)iOtsr>VrNurnc Facililr IDN(faptiltabic) $.Cet7if[tatioie litE�,rFra sect fir, r Rom,s Ur
3934 Raleigh St. Charlotte, NC 28206 �GeCfG /�G6JTi 8/22/2023
Ph)sleal'Adtrcss.Ciiy:and Zip orlIIlet.,orCCYllr*4 We Colitre:Ior 0tLVt11(hen:r D,tic
Mecklenburg nen!3}'.si�_',g lhis•freii8, I leerehy certify dFkrd di rrellrs}ii�ar(here)abniafaned hit aunty Parcel ldcntit�itknNo:(PlNj rlccrirtlUhM wall?J3:S'.'Nt-4C:0212.010tl.ur 2f.0?O(11F'r1! ndasJntc!!n_ri SlrtrtrJarrcls
anrJ lJera rd sop}aJJris rccurd Jens be ern pen itJed dr?7Jre ive!!caner.
'5b.)<attituds and l�ngi.Ttitle an,tl4�It'coaltttinuteslsec�ndsrts'd�sinta�iic�;t�cs;
(lrt,alQ Coatd,QItl giro ub{s itne I�) 9.Site diagram or additional ytell detally:
35.150677485 You tray use the back pf this page to proAde-additional well site details or%yell
i•°- -80.474854975 �4' abaudonnte it&tails. You iva}•also altuclt additional p l s ifafeczcsan:
C6NSTRIIC'r[O,N DETAILS ON WEL14SI IlkiNG A1341VDONED S1TB&fjML MSTR CTfONS'
:QPIntlr nett cvrtitrticdrr�rt ncvril(sJ!I'uwtllr k. .Par_qwr rlple n�ariure c) ran-irertar�,tpph•
hells ONLY a ith 1).w Fvute tr7lcibveeebri�r a�tinrhaanewt,I oa con..*„bm!!are jg1nrr
10a: For All Wells: Subinit this farm within 30 d;Ws of completion of well
6a.Well ID.4sMW-2 abandonnicat to the following;
Divisin n of�Vuter Resourcrs,Infarmatino Pr0ee_5sing Unit,
Gb.Total well depths 28 (ft.) 11511 Afail Sci-licc Center,Releigh MC 27(&J-1617
10U.EI iriiection Wells: In addition to seDditig the form to the address to 10a
6c Borehole diameter:2 (ha,) abo%�e,also subodt one:copy of thus forni witlriii 30 days of eompletidei Uf t%•ell
abandvmrl�'nt to tlic folla%yiitg:
btl.Water lcvcl bclost•gronnal surface• 17 (tt.) DiAsion GfWi olerReiouries!;Uudeakrortnd MJLe-ion Contrp!Program,
TG3F kail Scnicc Cartier,Mdci h,NC.27094636
6r-.Outcr casin Ica if[mown• 1[lc For�'vratcr Sannh•&inhfi an Welly: In addlti0n to sehding'The form to
g ( )A -(#t) tire-addQess(es),1b0t•e, also Submit'one 6opy of this'fotnt %�itltiti 311 days of
completion of-�ell a6ando cnt to the cutinty lwalth deiiartmearf of the couray
dL Innerca.44n0niling Irn}nh(if Imn.wnj: (gt,) %viICrc;ibalidoncd,
69.Sci•iva len#h(if lwov'):10
l {
FOme G1F-tr1 Nonh Carotim Deparinr:oi afEnt•isunurent aril Narumt Resol�+ecs-L Is uian of l'inrcr nisolti s Reseed Augo

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WELL ABANDONMENT RECORD For bricriml vw'ONLY: It
This form can be used far skate or nw10p1e Wc1ls
I• i
L Well Ca"30,41elor�7nformation-, WELL ABANDMh1ENT DETAILS
each Thompson 7n.Nuather 6Ndis being;altandnl Ld. 1
well'CorAwOrName(armscilnuPj!ipersariallyalxandan[uo+tLtl.pnh�ll,erprapesly) RV wirlopre rr, oi rt�,rr, or- tari-,itirrer sup;v}' webs ONLY wah Ike smote
cart3rrrrCfl,Nr itf arciruuneor,}Cur rimy ni'ImAr wrrjinx
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TIC%V01 Conlydgvr Ccrl ifir~]lion Nu,rb¢i 71t.Agiptninmate volume of wStitr'ATMaining,in lvell(s); {Cat)
SAEDACCO F0R'%VATFR$tJPPI,YiYEl
Coappart+Name 7e.Tti7tc of disinfectant used:
2.tiVell Construction Fermtt q:70003022, ,WM031210
fist rrll uryallrrrble u 11;ermitx'(ix_i'uvCh',Sri te,1'urdruxe,fi�ection,cicl iJSnm�r. 7d.Atnoutit i)f dlslnfeciAnt usM.:
3.tiVe11 Use(cheel:tw`cll usr): ,
- — -- — --
Water Supply Well. 76,Scaling materials used Miceli all that apply):
dAgrictilturr! 171V itmicip;tUpubli5 M Neai Ccment Grout la 13e'voriite Chips or Pcllets
00=1111crnr,•tl(Hcatiik[Kootiug Supply) ❑RcsWntial Water$Ytglpiy (single) ❑Sand Centent Grout ElDry'C kv
❑Ilidustrialicommcmial ❑Residential Water 5bpply(shared) ❑Concrete Grout ❑brill Citifings
❑iari Lion 11 Specially Grtitri ❑Gravel
Nog-Mratcr Supply Well; 0 Bentonice 51uM, 0 Other(esplaiti under 7ig)
I;flMnttllC?Nr� ❑Ri�arar+• .
Tnj€ctiou Well: 7f,For each Material selected above,proAdc amount of materials treed:
❑Aqutfirltecharga+e ❑GroundrrdterRentedwtinn Neat Cem.:471b ,Wtr:3gal. Sand Cem.:lb ,Wtr:gal.
p 4qutfer SEontge ir1k1 Itc in'rn+ ❑$:tliltiti=Barrier
OAquilerTest .ElStomi esterDnaieutee
❑txpr interdal TerlwologLr ❑5ubsidetica Catsiinl
iW,Prwiide a brief description nFtiae abagdanment proctvlurc:
[1Geothemial(Closed Loop) ❑Tracer
00evhermal(Heatlit C.00lin Return) 001herieti laiuundor7r,l Grout gravity fed through tremie from the bottom up.
l r.y , _
3.Datew'elI(S)abandoned: 8/22/2023
Sa.Well location.
Abernethy Lofts
Facrlit.Ahvrrrldamc 8.Ctrtif[caflon: +, , ' Ur.):
1 racililsllla(iE�ppliwblc) - / [3�r�Cu�JG
3934 Raleigh St. Charlotte, NC 28206 /fL8" �J�i 8/22/2023
Plu•sical Addras.City-,and Zip rrrgtnn in C+r<iYx,t 1+1c Contair ar 1Ve31[j,ertr t%au
Mecklenburg ,si rliog fi{rs gFrrlrr, I Jrernby cerPijy'Choi file 1-144 rt-as(it-ere)t0andoned in
Couuiy Pbrcel ldcnlifr�]Lwa.(PINj 7tr�x,rilcrluc milJr i74:wCIC ti?C,tlllt0.ur2r;,{l?t?p lf'ell Civasdrdtcliort Sfort_eknds
nrid lhcrr atCap1•o•filris record husbeen piuvided to theweld aiiiler,
5h.I.'itfudsartd iritt�i.#udo in ticgnsesfntlnuto:slsecgndsbrdccnl;yl iicgt+ccs:
(i1`75'Clt E`t:id,ct,�:tntrl,tns u5 illiC ,r!} 9.,Slte diigr m or additionalweil detail:
35.150671553 _� -80.474941364 You tuav use ilia back of this page to'irovide additional w2l site details or Well
-- -_ - kV abaridounieni details. Yoii tuayr nl$o aitarh-ai itiuual paves if tiecc�sari_— _
CONSTRIK- ON DETAILS OF WELUS)BEINS'ABANDONED '+IlBbii7"fAT.TNSTR .TTONS
:ttfr{dr 11-eP vorrrraelion ncnrdlf l dr'dvi ildble. .l rir trc„hl;,lr ierJrrtion or M1J1Yteav' l,pp�y
11•418 ONLY 1r•iih ilw S12we rwrerr cfiarar'rz�tirreharaa,eaaL iou exrrr snlunit�wtefsnrc. 10U,For All Welts• Suhinii 11rEs tnnn ri•ittdn 30 days of completion ai'well
6a.Well IDJe:MW-3 abandontruitt to tho follovving:
Division of iVuteeltesaurces,Information Proceming,Unit..
6b.Total trell depth. 2 6 {ly,} 1617[Bail&firice Center,lialeig h,NC 27699-1617
101i.1 nr TnieclIon Wells: hi addition to�".udigg the foram to the address in l a
6c.Borehole dlanictew 2 (iu.) above. also s6ndt one Copy of tliis form.Avilkii 30'days of cotitptetiou of it ell
ab5ndomncttt to[Ire fnlln�vireg:
Gd.Watcr level belowgou nd srface;.18 , ) a ram"
1636[11 rit Senicc Center,Raleigh,XCt 2760-1636
i
Gr.Outer eacin len tf known• 1.klc•Dr Rr etet^ uniah &Tnfectlon iVe11v; ID addiiioD to sending the form to
g ' ) (#t} the addiess(e).above. also sus iiilone copy of this foe' a' thin 36 days of
conipt€tion of,,Ncfl ahandmumnt'to the county Faith depiiitmetd of the coungy
6f.Inner easin ftnbing,,-trnj;•th(if known):- A) rvl;crc abc�mtivncrl'
f
6g.Screcu leng th(if kno u):10 _ 00
i
r
Fom3 GiN-10 North Carolim Departncril Oi'Em ironnrcnt m-d N3rt-1 Raso1LTcs-Division of 1WEcr I.CSOHTCVS Revised Aagu9-n 13

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WELL ABANDONMENT RECORD Far IrAUdUl Usc r)PTI.}':
This foi m can be used for singfe or multiple Wells
1.Well Contractoriorer•m;ttion ABANDONMENT DET,;kl .5
Zach Thompson 7:L Number U hells being allando- etl. 1
Well emlmaor Name(or wal.O%vPdrzmor�tJyals�ndpritng�i&6nhWherprepeny) Flu• wirlrople fifretrolr w' tvxi-utiiter sltprlj' walla ONLY wIrb 8w spjJly
' rats[rrrcrluYr:i'nt�uardrvirll��rJr,}+ue ciur•rahlitl't alejJrrn;
4478-A
NC Wc11 CPalr�a0r C0 ift�ljon Nlnrbct 7b.Apprnicimate►rllutne pf sFat K;remaining in vv'cll(x}; (gdl)
SAEDACCO FOR NVATF,R SUFFLV IVELLS ONLY: -
Company Name 7m Type tot disinfectant use.d:
2;"WellConstructionFcrmttM:?0003.022, -,WM0-31210
Il r�!1 rl�ipfJcvble.url!}a rmlir t.r C+rurth',Slab,Yuridme.hErea0V,-ek.f tfbatoan 7d.Amount of disitlfectsillt USti41'
3.well use(check Wc11 use): --
Water Suppy Well: le-Scaling materials used(check all that apply):
l7)ari atit[{ral 171v9[[nicip,[11Ppblis M Neat Ccnient[.hunt I I Q 13cnttatiite C4ips prl'ellcls
ElQ=Ihemlal(4Cg0nP,RCA30li11n$11pplS) QRcsidrmiat Water S�rppb-Csinple) ❑Said Centel[[Grout ❑Dry Clef}'
❑Irld1M1lrW!(:}nn LC[Ci31 ❑Residential Water Supply'(hared) ❑Contltele�GFOU., ❑Drill Cuttings
❑lrri •tlon ❑ Specialty Grrlttt 'D Gr.lv'el
Noa Water Supph 4Ys11; C7 Beiltatate 5lurtg Other(explain under 7g)
®Moititorirte ❑kidoven'
injection Well: 7f,For each material selected above,proldde amount of materials used:
❑Aquiterkeeharb'e ❑Grntritdyrattrkentedilition Neat Cem.:471b ,Wtr:3gal. Sand Cem.:lb ,Wtr:gal.
EjAquifer Storage Fd4 k'ecovmy pS:ilinih•Darner
❑Ai uifei Test ❑Stomnv Ater I)rs naee
❑Eiperiuiurital Tetilluulogi ❑Snbsldeixe Cotriiu] 7z provide a brief description of the altandunment pr codure:
ClGeathertnal(Closed Loop) [STracer
Meotherinal(Heatin `Coolln Return) 00dwr(aN lain tinder7.) Grout gravity fed through tremie from the bottom up.
d.Datewell(s)Abandoned: 8/22/2023 C, _' --••ff }
Sa.Well lucation:
Abernethy Lofts S EP 1 2nL2z"
Facrlit)rt]+lnrNaorc FxilUyIM(if uppli:abic) S•Ccrii(iriNdit: Illi0ifY2;tc^r t��f,^.n11,s �j ljrA
^^� Dt9Y GJJL lA
3934 Raleigh St. Charlotte, NC 28206 ` /�(,B�i1i 8/22/2023
Physical Address.City,mid Zip gmiiwoctrCertlrnd14' C-<nitrtcter(it Weil 4nvtre Dim
Mecklenburg 131!.aignhtg 1his,Jarin, I lremby semi v-Mal the well(v)was(were)ahmidoned in
t nutib' hares]Idcnl3licat}[tnNo.{PINj titt'vrrlaixe mrth ISA XC:IC 452C.0100.i r k.0200 irrdl Cctras7iuE:jiun Stf g&,rrls
slid 161 a iopy o(lhls record bus hegira provided to the well C+tf77E'F.
56.I_- t11UdSan{I ipngiVdcin degr•eestmi<Y4egdwcon{i591'd6 iltt!l[1C$rSe9:
(Irtseti r`h tw,nits 4urhtlls iv sitirclsta) 9.Site diagram or additional R•ell details:
35.150979286 You r*use Elie bade bf this pa
-80.474843776 ge to prov'idd-.additional iyeU site details or hell
-- �. _ ---- �Y- . abt[ndannretude[ails: You[ws}•nl�:rltaclfasiditib�al�ivasititec�saii•_ -- -- �_'—�
CONSTRTI(-MON DETAILS OF WELUS)BUN('ABANDONED TBhiITTAi.fi1STR T .TiQ 1S
:trlruia tnrl!ttR11YLC11�rt rirnrcl(sl iJ'utrcitlreGla !cv mulrilalr byeelon fir raga-uertar x:tpply
rrella ONLY iriflt rl svut�ralr.'srxrxllvn'olacrihntr.+rcvJr,i�u rvra dtlunr!are�JIAfP. 10a.Far All WelL4: Submit ihi5 rG n1 wirltin 0[lays of cotuplction of%wil
6a. *yell ID€:MW-4 ;INinduumcni to Etta followkq;
Division of�YutcrResanrem,Information Froer-Ming Uoft,
6b.Total well depth: 37 (D,) 107 111ai1 Seilicc Cenci',Raleigh,NC 275994617
1(1b.1 r TnlecWnn °ells: hr addition to seDd"tng the form to the addless it] 10a
6c.Borehole dlatuctcr:2 Cl a.) abaae;also subath otte.Cop%of ibis f0fin ivitliiu 30'dliys of einitptetior i of iy6li
abaiid6natt It to the tollavving'
6t1.Water Icvahclo+t (ft) Dhis[onofWJterRrsourees UnderSrtittrrdItijectlunControlFrtigratn,
gratund Surface;.2 6 163611tA Sense 1(alter,hale i�O,MC 2769')-1636
I
6e.Outer mkinn length(if hino rn): (ft) 1E1e,Fttr R%ater. Stetvnlr 1Pc Tufcctfan Hells: h1 addition to sending the forna to
the addresS(CS).abo}.te. also Subtuit:alto 6opy of this form vvitbia-16 days bf
corrtptetino of well a_handoounent to the county 1=1th deprtrjment of the county
fit Inner tasirrt tnbio g ttmn th if ima.wn: 27 v;-l=abandoned,
6A.S&L-en length(If IC>ion1l):10 ft.}
Parer Ca&Llo North Carolina Depoftm M afEntiroamcw an i Natumt Rcsomres-Disisfort of 11.9ter kt,;owccs Revised Augusa-V I3

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WELL ABANDONMENT RECORD ORD For"Irncrmrl u.ONLY:
This foam can be used for singly or nits.iple wdls
1.Well Contraourinformation: t,VELL ABANDONMENT DkTAIL.fi
Zach Thompson 7Z.Number of tsdls being abandoned: 1
WelfCoreracynrN;2kue(ar atrasihtoninexellonlisilrerprepcny? fca V11flople. 11j'(Wro,r a mnFritih.r suppy.y wells ONLY Led) If•e sane
C,n'ter/rr£f1GYb'!.`I'r7)i'rli:Vu1fa71f,}err?ccvr,tt"Mr,a,twforin•
4478-A
14C NWI CgnlmGor CcH iTr�rdon Nnrrbci 7b.Appn}acimate vrtlumc of ifat--remaining in n•ell(x); (Pt)
SAEDACCO FOR WATER.SUPPLY WEI,j GN V;-
convany(Jame 7e.Type(of disinfectant used:
2.Well Construction Permit 4.70003022, _,WM031210
Lw irll irlipIhubh uell ormilr f.e.Cvary,Stale,J'urjame•Lreciiorr,efeik�rkmiwu 7d.Amount of d{3irifectiltlt USL4I'
3.We11 usr(check:isem age): - - - --- -
Water Supply Well: 70-Sealing materials used(chcel,all that apply):
I
❑A�ri ultttrtl []htttnicip tllPttblie W Nqt Cement Gtottt IA 13cwo6ite Chips aPepe!`,.
1ICC0Iherr7Ml(Ikcatinra'Caglin8$nppty") I7RcsWntitrl', Ater Supph•(Single) ❑Sand Centent Grout El Dry Clary
❑htdustrialJC:omnwi;ial ❑Residential Water 15upp4•(st>3red) ❑Concrete Grout ❑Da Cuttings
offrigation ❑ Spetialt}••Grout b Grivel
Ilan Alratcr Supply Well; I I Bentouite Slurry Ci Other(explain under 7g)
®hlotritorvie ❑Rtcovery
injc-e iou Well: X For each tuaterial selected above,provide amount of.n-aterials used:
❑A.uifI- ..harge ❑Ciniuirdrr:rlerkernetliiuibn Neat Cem.:47.1b ,Wtr:3gal._ _ Sand Cem.:lb ,Wtr:gal.
pAquifer Stontgn r04 R•xev`r tt, pSa iriity flamer
❑Aijnifeir Tess Ee
❑Eep mrrental Technology ❑Subsidenc: Coo tol `J;,Provide a brief description of the abandonment prom-dure:
l7Geothennal(Closed Loop) fSTracer
®Geo(hermal{HPw➢n 'Coon Retum) 1�-lOther(explain tinder7n) Grout gravity fed through tremie from the bottom up.
d.DatcvscU(s):tbandoned• 8/22/2023 ! r 1 4 F
C-)
Sa.Wen lucation: Z023
Abernethy Lofts - infoi`h
-- 8.Ccrilf[ritlatt: ( � l��a
Facilit}•iChi•ri,:rNarnc Paailrl}•ln.i(ifappliablc)
3934 Raleigh St. Charlotte, NC 28206 /fL6�/1i 8/22/2023
Physical Address,City;and Zip r}tSlnsC irf CCrtilxyi 1'le3 Caurrr;ior try ti'e71 fhsrr:r Dim
Mecklenburg lit'.signlrrg.lhrs farm, I helldhY certify,dhrrd the lt'PI1�S)rra-T(ir•ere)abandoned h?
County farce!1d.nlift6Ikallo:{PINj arcxrrYlance rvflh 154f,NC-1C Alt'.,Of aq.ir i:C.0200 fF'r1! Sfnnrkirt,rs
and lhi f a copy afllris record has b�era,vr»vieferf to tire well c+rtdrer.
Sb.i at tudeand lone.ty-de in tLcgsrsesJmfnytesJscconds+ard+c tital degrees:
pr..ti41t C 41,(r,x ltrlly,thi �ii3ieiC,y} 9,Slte.diagr to or additional�•cll detaUs:
35.150771285 You m*,use Elie~back bf flib Irage�to pwide-additional well site details ter well
__]ti - ____-80.474823246. }r_� danntentdetails.-Ytauma�alse:ales![3al{iitiuvalpagesifitecessart_ ---
CONSTR1it-nox 6ETAILS OP tiVE1.,L(S)BEINC.ABANDONED &T_BNffTTAI.TNSTR'ilr_.TiONS ;
:tldrltlr 71 ell crrrnJrrlydlart retxrrell l'if arr�ilyd�le. leer mnlrlple uyectlop uu rwn-nwar sd,pFr�r'
uellx'ONd Y rrJ1h rL�i scare enlislr+rt)a,eii ti,rihu;n,crrL ru exrn hrbmif ulte'lirrrrz Mo. For All ?We114• Submit tltts form %vithin 30 d;}V5 of completion of well
6a We IDg.MW-5 ab;ind4luttent t6 the fgllptiYin�r:
Diyision of Water Rrsourees,Information Prueessing!Unit,
6b.Total sell depth' 30 (R) 1fi17 Mail Sei-vice Center,Raleigh,NC 27094617
30b.1 r U11CCIION 11'ells: In addition to seudittg the.forat to IIis addres'in 163
6c.Borehole diameter;2 above,also subadt one copy of this turn►ii'ithin 30 days of eotnpletioii of t4ll
(lu. 711rsnrinnrllerd to rill following:
fd.Watal lcl heloit 21 Pitiis[ottpf Fi7aterRisources,Utrticrgtvittnrl Itije.t[on Control Program,
ground surface: (ft} 1636 i1 ail.tervicc 4=enter,Raleihh,NC 2169r1-1636
6e.Outer c[sing IcnE�th(if Imtiyyn); (fw3 1llr,Fnr Rrated,Srrnnly&inlect[an iVclla: In addition tti{ending the form ro
the-addiess(es).aboET. also submitl bbe copy of this fgim Acitbin"air dot's of
rompt�t63 of.%ell abandonment to tlic"county health dcparimerd of the couvS r
6r inneriasinonbin l n eth dlarnvyn• 20 ti`j rcaExtndoncd.
6g.Scrtvn length(if knats-n):10_- - M.)
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