Mecklenburg_Well Abandonment_20240318 (4)

WELL ABANDONMENT RECORD For lnkT al Use ONLY:
This form can be used for single or mtdtiple»ells
1.Well('ontractnr Information: WELL ABANDONMENTDETAKS
Rich Lemire 7a.Number of wells being abandoned: 1
Well Cortracsor Name for cell owner Nmarra y.6undon tg well on hustlter property) Ftw twuhirle i)lMt rare w• wm-uYdiv s ly isefb ONLY *A Ike some
t�otr+4xtt ri ot6autdwrtnrtrt,)tier cvm watt owfilrtn,
2593A
7b.Approximate snlsme rd ester neu4atnlo6lsr wdl(a)VONB I Mal.)
NC Wet CorAraerttt tYrlitrcalioa Number
SAEDACCO FOR WATER SUPPLY W>JX$ONLY:
Convarn Name 7c.Type of disinfectant usrd:
2.Well Conatnwilion Pero*#:70003186
lase tdl crlkxt9lr well permiCr d r.r -:,,:r uHuiKe./glaitiont rir:).r1 tiwrn
7d. amount of disinfeclAnt used:
3.Well aw(check-we*rat):
Water Supply Well: 7C.Scaling material.u..c41(check All that apple):
❑Agricultural ❑hfunicipaltPublic D Neat Cement Gran 01 Btntonite Chips or Pellets
❑ kothetmal(FieatinftlCoolirtgSupply-) ❑Rcsidential Water Supph tsingle) 0 Sand Cement Grout ❑Dri CUv
❑IndustrimPCommercial 011csidcnttal Willer Supph (shared) ❑ ConMie Grout ❑Drill Cuttings
01"imuictin O Spedatty Grout ❑ Gra.el
Non-Water Supply Well: 0 Bermonite Slurry 0 Other(explain under 7g)
IMMomtonng C1Recmtq
Injection Well: 7f.For each material iefected aboer.proside amnunt of materAN u.ed:
❑Aquifer Rechvrge CFGrounduattr Retttc:"ion
❑Aquifer Storage and Recovcn Matimly Baffler
❑Aquifer Test oStomnlatct Drainage Bentonite. :1 Olb ,Wtr:gal__
OExptrimetvalTrxhrtotogy OStrbsidcoceCouinA 71t.Prmide s brief description ofthe abandonment procedutr:
DGeothemtal(Closed Loop) OTracer
BENTONITE UP TO SURFACE AND CAPPED OFF WITH CONCRETE.
Meothertiviil OfeatiniglCoolingRclumf ['100wt nunder7 )
4.Date w ell is)A hall doned.. 2-27-2024
5a.Well location: A„
LEVINE MUSEUM
Pacrnig04wrt Name Facility 1DN(ifsppticab1c) I�u 8.CHtlliatlaa: K if 8
324 N. College St. Charlotte, NC 28202 Y t :', ? �a2/2-9—/2-0-24
~ Will -f7dwC
Phisi[alAddicu.City,and Zip S ipd iQ WCtI t"oHtOCMr at J(�
NECRLENBURG 08002401 13)-,eignning t)iis form. I hemkv cergjy that the wr/1{ci was(arose)abtundated in
(oat 1, Pa eel Idenut►-ation No.(PIP() (ar m4 a with 14A?1CAC 62C.6100 or 2C.6206 fret/ConlY W-ftorr Srrm&Wdv
and lint a cop),. f ibis record has been provided to the well owner.
Mo.latitude and tonlritudc in(1cerve0ninutes/.1•condh or decimal dogrms:
ill"all fw:Id.utk Lit lung h 1401 1111) 9.Site diagram oraddidonatwrN details:
You may,use the back of this page to pnrn ide additional%vU site details of well
K W abandonment details. You may also attach additional pages if ueCestant.
CONSTRU(7nONDETAIISOFWELUS)OFIN(: AB DON 1) yS,UBMITTALINSTRQCTIONS
.Itkwh well mnsinitiaw rrewrd4i if•Ot ialik. Fcv mrrttef4c oye,t,u.i u rwa -447-M16-
NY14ONLY wick the mam trier s&mN AWfiow 10a. For .all Wt1b, Submit this form within 30 days of completion of well
6a.Well[Dry:TMW-3
eharrtionntcau to the follnsctng
Di%isiun of'll ater Re.iurees.Information Processing Unit,
6b.Total welt depth: 20 M) Its 17 Maid 4 n ice Center,Raleigh.NC 276"-1617
10b.For Iniectivn 1Yells: )n addition to sending the form to the;address in l0a
6c.Rnreholediameter.1 liu.t above.a6o atrbitm one copy of this form within 30 days of completion of well
abandonment to the following
Dhlsmnof Water Re.ources,Underground Injecdou Control Program.
bet.w'atcr k1r9 bilnss l round.ttrfaec: 15 eft) 163(t Mail`mice Center.Ralci;h.NC 276"-1636
10c. ERr Water Sunniv& Inki Nan 11'ells: In addition to standing the form to
6c.()utrr ca.inZ Icn�th iif Isoss nix 10 (ft) the addfessles) Vie, also submit otic COW of this form within. 30 d*1 of
completion of wcil abmdomnem to ilic Comfy hrrtth departweal of Ole court,
where abandoned
6f.Irmo casinyttubin>;Icntnh lit Imawnt: (ft.1
(o-_.Screen Icn:;th(if knows):10 A)
Form GIVI.1tr NorthCarotirn Depmoncut of Pmirontncm awl N tuml Resoo-mcs-Dlstston of Water Resources Pcs tscd-Nuprst 2011