Mecklenburg_Well Abandonment_20240116 (4)

WELL ABANDONMENT RECORD: pad internal Use ONLY-'
1:Well Contractor Information: WELL ABANDONA1F,N•f DETAIfi�S,'
Don Warren 7a:ForGeoprok. FT or Closed-Loop Geothemmml Wells having the same.
Well Cantmctor.Namd(or'wcll owner pcnomlly abnndoning Wcll on hi.9/hci Property), well constmetionldepth only 1•G1V-301s needed; Indicate.`OTAL NUMBER of
3581-A. , webs abandoned: l
NC Well Coiltmctor'Cenirication Number 7b.Approsimafc volinme ofwater remaining in
.Mid South Environmental FOR.WATERSUPPLYWELLSONLY::
.Comp.any-Name- !
7c.:Typeofdisinfectantusede
2.Well Construction PerLnU#:.
Ltsr all applicable well construction permits(Le.UIC,County,•state,L'arimtce,'etc.J iJ'know•ir
7d.Amount.of disinfectant used:-
3.Well use(check well use):
1Vater Supply Well: .7e.Sealing ninterials used(check all that apply)
OA griculttual ❑hlunicipal/Publie'. s"Neat Cement Grout ❑.Bentonite Cliio.or Pellets
❑Geothermal(lieatinglCooling Supply) ❑Resideniidl Water Sttpply.(single)• ❑Sand Cement Grour p Dry Clay
❑hldustrial/Cvnlniercidl ❑Residefitial Water'Supply(shared)' '❑Concrete'Grout ❑.Drill Cutth gs
❑lnri ation . . ❑.SpecialryGrout ❑Gravel
NomWatcrSupply Neil: 0 bentonite Slur ❑'Ol her,(explairiunder7g)
NiMonitorin9. ORecovery
Injection Welt:.' X.For each material selected above,provide amount of materials used:
❑Agirifer:R&h&gc ❑GroundwaterRemediation 75 IbS grout
❑Aquifer Storage and Recovery -❑Salinity Barrier .
❑Aquifer Test. OStormwaterlhainage -.5 gal Water
❑Experimental Technology ❑Subsidence Control.
•7g.Provide a brief description of the abandonment pr occdare:
OGeothemtal(Closed Loop). ❑Tracer ;
❑G`othennal(HeatingiCoolingRchtrn) OOlhcr(c�plain under 7g) Per �JrA•NCAC'02C:0113:(d),.abaindonmehf
was completed by filling th e well with.
:i.Datewell(s)abandon 6d: .12/27/2023
Portland cement.
5a.:VYelllocation:
Woodward Avemie:Site 6-2@124
FacilitylOwncrName F66fity,1DN(if applicable) S.Ce. iti ion:
t11ty v �^-1 �1Eh,a �l.�tr'iA
1022 Woodward-Ave,-Charlotte, NC 28206 P-12/27/23.
Physical Address City,and Zip Signature-of Certified Well Contractor orWell Owner' M'Date .
Mecklenburg
'By signing.thk fon)t," -hereby certify;that the.well(s),w&v'.(sveie)abandoned in.
County. Pareel.idendeiication No.(01N) accordance with 75A NCAC 02C 0100 or 2C.0200 WWI Construction Standards
and that a•cop}•gfthis record has,bedti prorided to the well owner.
.5b..Latitude and longitude in degrmstminutes/seconds or.decimal degrees:
(ftell.field,one lat/long is sufficient)
.9.Site diagrarnor additional well details:
35-.14159.10'i N.-80 49'56.56" �; You may use the back of"this page tbiproAde additional-.vcll site details or well
ba andonment details.'.You n,ay dlso attach additional pages if necessary:
CONSTRUC rION'DFTAii S OF WF,LidS1 BFf NG ABANDONF,D. SUBMI I TAL'INSTRUCTIONS'
Inac)rwellcaishuctionreeord(s)ifm•oiloble:Foriirollipkinjectionornar-watermipplrwells
ONL P with the smne consinielionlabandonment,:yotr.can mibMit one four
t0a. For All Wells:• Submit this:fame within 30 days ofpompletion of well.
6a.Well ID#: MW-� abandonment to the following:.
Division of Water Resources,-Information Processing Unit.
6b.,Totalwell:depthr 20.0 (ft.) 1617 Mail Ser�viceCenter,Raleigh,NC 27699-1617%
'10b.For Injection Wells: In additiop to sending the form'to the address in,10a .
4.25 above.also submit one c of-this:form within:3*0 da of letion.of well:
:&:Boreh6lediameter.. (in.) copy ys inP
abandonment to the following:,
6.&\eater level below ground surface: (tt,). 'DiviAnn of Water Resources,Und(er�round-Injection Control Prrwrrm;.
1636 Mail Service Center,Raleigh;NC 276991636
'6e.Outer casing length elf known):-1.0" (n.) '10c For Water Sunnly&Iniectitin-Wells:•I6 addition to.sending the form to'die',
address(es)'above,also.submit one copy..ofthis form'w7thin.30.days of completion
of',veir abandonment to the county health:department of die county where:
6£inirer casing)lubinglength(if known):: . (f.) . abandoned.:
6k.Screen length ifknown• .10.0 j
Foim GW-30 ' North Carolim Department of 6m ironmcntal Qmlity-Division of Water Resources Revised 2-22-2016.