Mecklenburg_Well Abandonment_20240318 (3)

WELL ABANDONMENT RECORD For intnrralUseUNiv
This form can be used for single or mul6pk,wells
1.Well Contractor Information: WELL ABANDONMENT DFTAIIS
Rich Lemire 71i.Nrnmber of wells bebry[abandoned: 1
Well Coauactor Name(or astl4x nr r persotntly tdiandoMng well oa bui/BCr propely) For muhWe enj"an cw +delft-ONLY with tlh-
toaft rcum o6eirAmmtrnl.}vie cross hmm torah:
2593A 7b.Appmxiaoatr vobuee of crater rtemalnl"In wTeh(#JFD� (cal.)
NC Well C'ontrrctorC�rtifiCUUpItT'iLam6d
SAEDACCO FOR WATER SUPPLY Wirt:t..S ONLY:
Coe v=1 Name 7e.Type of didrifertAnt u+nl:
2.Well Coestrwction Perak p.;70003186,
Lur adl r,rr lcutlle we11 petwo o.r*.Colt i),Shire,t minder lnjact/nnt ek 1 tI t�r7i+M
7d. %mount of disinfeclAnl u.ed:
J.Well air(check,well mite).
Water5uppl.Wen: 7c.Scaling materiak uwd icheckap that apply):
OAgrmihural ❑hhmicipaMblic C] Nett Cement Grout O Hentotwte Cbips or pellets
❑(isothermal(Heatiu*+Cooling Supply) OResidetuial Water Supply(wiry k) O Sand Center*Grout O Dn Cta%
0Industriat'Commercial 1311 idcutial Water Supply%hared) O Concrete Grout ❑ Drill Cuttings
olffigation ❑ Spr6ialh Grow O Grand
Non-Water Supply Well: U fk4lonite Slurry. 0 Other(explain under 7g)
mmolmoritig ❑Itecorrn
Injection Well: 71.For each materlal selected above.proidde atment of material u%ed:
D Aquifer Recharge ❑Gmtnrduvitt Rcurediation
OAgmfcr Storage and Rmovcn ❑Sehnity Bamcr
OAQuifcr Tcat OStommiucr Drainage Bentonite. :10lb ,Wtr:gal.
OE,penniental Technology° ❑SubsidetiocC.onntrol 7g•Pmiide a brkf dcrcription of the ahmhmment procedure:
DGeothenttal(Cloud Loop) OTracer
BENTONITE UP TO SURFACE AND CAPPED OFF WITH CONCRETE.
OGeothemol(HoOMEooli2g Rcmnr) nother(e min under 7g) _
4.Date ri,Wj)8br.odM L. 2-2 7-2 024
St.Wen location:
LEVINE MUSEUM
Faciloyoisr=Namc F:r:Ati, Ir)rrifapplw.,ablcr 8.Ccni/icatioa: +Ct%�',�(i
324 N. College St. Charlotte, NC 28202 _ 2/29/2024
S r ifled Wdt Crhtor for qr Wed Ow-mr Date
Ply-sisal Ad�ess.CiiM,and Zip �►�
MECKLENBURG 08002401 B�'xagnittR dtac form* I hereby cer6A,that the»elliv) was tirmr a&widwwd in
t Pa rm wiltific"It No.01N3) ",c'ordime wilt IM A AC 02C 0100 or 2t" 421tW Well romiYtid Ao#,Vmu rnrd3
and bloat o cony of this record has been provided it,11re well owner.
5b.i.Atinadc Arid hongitadr ill de /MilatC%/Al/„cautlitordedmal dexmm
i rim c11 rm;ld.doe Lo k,ag r„arll"kmill 9.Site diagram or additional w-cill details:
You Play use the bacl of Qlis page to prop ide axldifiml well site deWls or well
N W abandomutut details. You nut a6o:itt:ul► ,ckiitronat poi ii nee tssary:
CONSTRICTION DFTAti S OF WELtiS)BEING ABANDONED gjrBMTITAL UNSTRUCTIQNS
.rt6ulr will mmirnown rrrwr&v,l j%wlahw Fir midliplr tmyeenem or nun-*.door aYpply
wr11a ON0 with the.ewm cvnsire,'te„n lurch ttmrnL low Wn submit tanB,�r/m 10a. For All Wt1b: Submit this foam within 30 days of completion of wen
6a.Watt tD$:TKW-1 ahalkionnrcnl to the following*
Di'lisloaaf Warm Resources,information Pn cemiling Unit,
6b.Total w,e* . 20 (h.) 1617 Mail Service Center,Italti.=h,NC 276"4617
lob.For Inlectlon Wells: In addition to imadirtg thefoml to the additss in 10a
6c.Brrrchtde diameter:1 tin.) d aboe• also submit ono copy of this form within 30 days of canp�ion'of wr:il
abandomncnt to the following:
Dhlsionof WattrResaurcee.Gndergn)uad InjecdotiControl Pn*rsrrt.
6d."'Ater h•s cl hchm Yround uir•f;i: 15 tD•) 1636)/fail Service Center.Raleigh,NC 27699-16M
10c.For Water Suptih & Injection Wells: In addition to sending the form to
6c.(hater cA.inL IcnZ[h of knonn): 10 [ft.l the addressfes) above. also submit one copy of this form within :10 days of
completion of wen abmtdmunent to the county hcahh drflartnicM of the county
a here atnndoocd.
6f.Inner cANinw'tubin;~tenthh(if w1onn): Ift 1
6g.Screen lcn2fh(if Lnonn):10 (tt 1
,*.�,m c A\-­ wad'Naluml Rewmccs-Dh'tslon or Waecr 1teS0Qmm Rnvsscd Aupcsr 200