Mecklenburg_Well Abandonment_20240306

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WELL ABAI DONMENT'RE ORD : FailntrnraIUseONLY.: : ,. . .
This[0ornt can Ifir.iiieilfejeiliigld.ditinitititeitit&. : •.......' -• : •- ',et' /) ... • • •
I,Well Crr4tr stor tnformattoaz, \N_)• A'EUt;AB1►NDQNMNENT D}TAILS
John.Eisenman 7e numberoflvdlsbeingabbtidobcd 1
Wflf64i. rorW,me(ottselleErmxptrsonatl) bini4iii, salton3 iloiii iy}. fox. mutrttth, ilr alleu► w nwryi e? ,girpptj t 1f ONLY ....loth, :he dish
• cronz�t0-4:ora`04.i ciitrnrrtt Ztin umr c to 6,4 f i in.
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NC 1Yc1}Canar�tiort cntt caliouXt nnbd; 74 Attpmximaic autume of nrf nenirwuig in rrelt(b)D 01.
• SAEDACCO>. :.. ..:.... :. IO�R VATEIt$V PI WFU O$ Y . .
Callan ]s, . . . 7'an to ii dtnnrcxtantu+tde na • .:
2 Witl Construction Ferran#.50001036, - ,'
Irct-a4iligtc4k.i.0.1.kru vt4i:r0W j Sib I'uriirO,;:/i rs#0i;-00 vri • ' . . , • -
.:,. ... _. 7d?Uutount ofdhinicctantusrvl.•..
3 %VdI uati.(cbcd.beds use}.- .
NVatrr .Supine Well • 7c Seating niaterIaLL used(ebecl.all that apple)
QAgrit uliargi.. GlMitnw p,7t/Pnbbi l NeatCenmut.(runt :f3 llet4onitcCbrps orPcilets':.
❑rroihcmtal(Hcaltni troohna Suppty) .p#esideutiai tV iti.S0 ptf:{smc ic)
Cl Sand Ccfttcftt Grout :.:.El 1) Clay
17 truiiisitittt/Cornnteneaat• . Qticsid• .eirtbiI Water Suppi (sb.ue t}:;. D COP.tr.O GtPut CI Dttf Cuttrnis
El St eeb1ty.Grout.;:. •Q ( et.
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Non tVatcrsunpl)wen , . .
17 C'11t0ta1fC S`it►tC4 •.,1• Olt.•,(.Y[?I 1, under 7 '.
>iflMonitonng:. t1t(ceit� r}t;':_ , ,
In eellon 1Vclt, aai nntduut of ateriatc sued .. .. ... rf�iflor cacti niaterl d selected shot cw proside
DAquifctl tt3r •DGroiiii4 rterRontedldtton_: .Neat'Cem.:941b:",Wtr:7ga1 Sand Cem.:lb•',Wtr:gal.
QAquiCet Sidi*rtttd Itd�rrasers DSAlnttt Damor
4Agti fcrTest; tlStomnvdtcrbriiaat • • .
DEq"nnhent it Ttr,iotq -.(7Sitbsidettme Combos` 7 Prrjyide st liixef description 4tthe...,• nmcntprucedure .
DGeottrennal(Closed Loopl •C]Tracer:
•pull.well out of ground, pump.portland through tremie to
tGeaihenutal U ectinn1Coo1borrltetum)•... t lOtbor(e�phuo`under 7m : ...: • ,
..•-•
surface, cap.with:concre
:. • • • te. to match,surounding surface
.i Dite r►dl(s)abandttneil. 2-20-24. t` -� ,,
• e .i „►L1\I L,3
5a.wpo tocahi.n;; . . . . •
Sam's Mart-:No. 7 .. • K{:IK.0 O:.LUL4 . ..
Fesn'lctyfOwn r tsntrla • >:a,.ilc tt>p ftPapplxubic) ti Certtilcatiott
into+.•aaen ar ^srtr�.fJ Urwt
2630 Beatties. Ford Rd., Charlotte, NC 28216 ,tom i <'- 212
�''`� 2/2024
Pin heal Address City;and Ztt► .., St,£tltt� , : -�a-r+Ica,4ts<ur 1,,. ?�ti-,,,ic Due.
Mecklenburg :-:;- -. . • • I3ye:,t n1ng ttnc.:M t :'� r>YUial tlw Yt {}zsns frret`t abandoned rat '.
(ilatsi` • • • tar el l&.ldi€ttehdonNo(PIN), acca.n-daitee u't,I -10-0 2t" ()IQ')o 2C (I3t}b.Tiell4'4nalrrtctIo i.0,:rds
. and)ir u rt copyo, 'thu tro-crrrtl liaa'b een nrinzrtai lv 1iiii i-It rmiiwr .
rib.Latitudeand t4pgrtwte in dcgrcc.4lndrrutcslccrn idsor decimal r(egmes,
(aril!tt<i.dtr<ttiikiii itickr, •:• 9 Sitediagramaraddtttotlal dtl:dertlls
Y ay sc to of Ibis Inge to to ti_ • idditicn tt yell bite details of yy ell
>- . - •N . ' .: :. ': -• . W; .abtttkdontneritiietatla Youinay alsoattac riddtttoitalp stf ecessan,
COAS1R1terit' t DETAILS iii-S'VnusY 13f~1ttiiC ABANDONED' ::;41tIMI'ITALINSTRLICTIOITS
Iflath tid(rnns'Itlrrl*<ncwrlllSe ai toa3t tc 1 tv nmlil:le Ut crtirut'ut rya i rtlrr su
utlts0:.• t'Y iifit 0.?..( rrtssf febut°cwrlcun�i�tirtt,}ar.. !t0.rfivsalt e/ 10.1.:Fnr Atl'•V etit Submit this foam:*ithut 3U'lays of completion o'r:::ll
-• pb ndonrte►tt tr t ltc fo lloi trtr ' -
Gu.1`ett 1D#TW 1 -
Dni lon o£SVater l2e urces,Information•Pro irng Unit;':
• 40.. • 1617 iltad:Seridd.Center.Rnl .t**IrtC 27G99 161? •
6b Totabxtieil depth •• (ft).
'lOb For Ititcctlnn Weil In addition to sending theiiatttt to the address in IOa::
• above also'01Juih 0.,.a,ii.i.s.,.,.4.:.f10
of thtis foitq within 3( da)s of.cuin•piettott of hell
6e.8orchblc;diamet4*i Y`2 cn). abstulonmsttt to'the fo1loitin , •• Dhviston of•W rtcr ltesoutie'Underground Injeexion Control P of raut
6d Watertcsd.bi.:**4und uface . , (ft,) .
.:. ... . .: .._... .. 163G lltxil Seniac`Ccnfct=.Italer�t,J�(:27G491G?G
Gc:putcr easi> Icn 19c;For V.`ater Snnniy'.&tnteciinn WcIls h1.*Iti ftop io sending the fonts to;.'
g l (If knotrn):: (II.):' • die 9ddress(es)`show,also 3ttbnlut one top, of ibis foam rtitbin 30:days of
t camplgtton of nett ak�tlortttictt'[ ll>c county ttGith i1Cp$ttntcrd of the cttti4y:
• 3D •abcrrr.abandonsd
6f'l'nnerutsing/tnhrag Month(ifiatonn),: • (ft.) .
•6g st Icrtgtb(if ImC yen) 1 Q:
,Behe (f).
ForntGW'U; NonabamticaUcpiiimcntofNanrom t;niaiNnturai.Iteso ccs-b»rsionofWatce csontn:s• •:.ttetiscd.lwsuslODt3:.'.

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WELL ABANDONMENT RECORD-
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• John Eisenman •--•.•'••"7.-• •• ' •• ••••••:,7••• - ' - 7'7'. -. • •••••••••7 ,*tiiniirstiiiiiilliilitinitibeitdeneik: ::•::-.:"..;• ••••:'•"•'.:-. '"',:.:- • -
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2630.- Beittiei•Ford Rd-.•,...'Charlotte,-•NC 28216. .: ...: -... •-•••• •• . • ..,•• • ----..7.:•••;;;:;ii•-:-.•• .....,:r-4- Ift.'3P.G7,:• •- - •2-(2 /2•924 •••• ,
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WELL ABANDONMENT RECORD For Internal Use ONLY: • .
1.Well Contr, or Information: WELL ABANDONMENT DETAILS
f/./i/�f (6, .eph /f2� f( 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor N. e(or well owner pe nally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
//'5/0 - wells abandoned:, i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 05.1pt (gal.)
Morgan Well & Pump, I N C FOR WATER SUPPLY WELLS ONLY:
Company Name granulated chlorine
7c.Type of disinfectant used:
2.Well Construction Permit#: /0 0/ 7 gA 3
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: 3 01_
3.Well use(check well use):
•
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural • ❑Municipal/Public 0 Neat Cement Grout �Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) CyResidential Water Supply(single) 0 Sand Cement Gt~',''•t`n, D l y Clay
❑Industrial/Commercial . hResidential Water Supply(shared) ❑ Concrete Grout L.—t• ❑Drill Cuttings
❑Irrigation 0 Specialty Grout M AK 06 2024❑ Gravel
Non-Water Supply Well: 0 Bentonite Shiny q,Oer(explain under 7g)
❑Monitoring ❑Recovery 1
Injection Well: 7f.For each material selead(r'YUde4ovide amount of materials used: •
❑Aquifer Recharge ❑Groundwater Remediation 1• 5
❑Aquifer Storage and Recovery ❑Salinity Barrier `S I b�
' ❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer � /�
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g) Peeked
PIP /S 'our (/vt,1/ / ay up CaS/9
'1` /ae/du) ,troops, . O.Fenftcted butt', f ,/
4.Date well(s)abandoned: a//3�aq �f J -J]
/.eIY uJi/i heAfoAlfe Eh�3 , iyafra h
5a.Well loocatil1on:
Chad ' �/1 Allbentevite. , Coecre wet/ MY .
Facility/Owner Name Facility ID#(if applicable) 8.Certifica i••: .✓—
..„...///
9a/a reel M. „If,/ d< / aV
Physical Address,City,and Zip re of Certifie Co•. ctor o ell Owner Date
II/hut/aidr
jf By signing this form, •• ry certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
' (if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
2 5 . 3T N �n V, g, W You may'use the back of this page to' provide additional well site details or well
3 abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS .
Attach well construction record(s)if available.For multiple injection or non-water supply wells •
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: ;)(
abandonment to the following:
Division of Water Resources;Information Processing Unit,
6b.Total well depth: Wit (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (9- (in.) above, also submit one copy of this,form within 30 days of completion of well
n abandonment to the following:
6d.Water level below ground surface: oft (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): x (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): K (ft.) abandoned.
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6g.Screen length(if known): fC (ft.) • •
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016