Mecklenburg_Well Abandonment_20240318 (5)

WELL ABANDONMENT RECORD For loop,I Use ONLY:
This form can be used for single or nudtiplr hells
1.Well Contractor Information: WFLLi.ABANDONMI"NT DE:TAUS
Rich Lemire 7a.Number of wells being abandoned: i
We#CoatsctorNow(orwcllownerpersotWlsah;m&intrrg++cllonhr0ierprotxtn) For erAVVe i,ttatrwr a nxrwYaer 3i9j*. , )we(it ONLY wrh the a,H•.
e»wtrrmr(rart is'i,rrida+rins pt,ftrw cm nil"it oft iuw
2593A
NC Well Coat►apor 117911i6catipri Nambcr 71).A ilimxlesate%m4lrme of stater rrmalninE in oorcl1(x#W IME (uYl.)
SAEDACCo
FOR WATER$VPPLY WELLS ONLY:
CompatyNam -c.T)pe of disinfectant used:
2.WdiCauus>ttetlon Th'otk tt:70003186
t au tans rgrptiobtr urU •rm�ts rid-Y'a+rnn,1!a k.l uri untie,/igea 1,un rrc;f.l tmavn
`d. Amount of disinfectant toad:
3.Wdl use(Shed,well use):
Water Supply Well: 7c.Scaling materials used(cbcck sit that apply):
OAgriathural 17hhmicipal lublic tl Nett Centcrtt Grow M Rentonite Chiles or Pcllcts
DGcothemnal(Heatittg,/Cooting Supply) ORamicti ial Water Supple(Single) D Sand Cement Grout D Dn Cbm
Dtrdustriawornmem a! DResidantial Water Supph,(shared) D Concrete Grout ❑ Drill Cuttings
Dirnwation ❑Speaalh Grout D Gravel
Nan-Water.Supply Wen: 0 Bectonite Shiny CJ Other(explain under 7g)
IMMonitoring OReco+en
Injection Well: 7f.For each material K4ected abolir.proOde amount of materials used:
❑Aquifer Recharge ❑Gmundwattr Remediation
❑Aquifer Storage and Recavo-, DSaliu*garner --
DAquifer Test OSlormuter Drainage Bentonite. :10lb ,Wtr:gal_—
DE,gx-n etxal Technology ❑Subsidewe Contrta .•Prnsidc a brief dcscriptinn of the abandonment procedure:
DGeothermai(CbWW Loop) ❑Tracer
BENTONITE UP TO SURFACE 2kND CAPPED OFF WITH CONCRETE.
OC*otherml ffleatingCophM Rehirro (10dwr(explain under 7g 1 —
4.Daft Wg*($)Abandoned. 2-27-2024 _�L: t;
sa.Wen location: " ' } 8 2024
LEVINE MUSEUM 8.Certification: (T t
Fa ei7q)00 ner Name Facility i)N(if appticpbkl
324 N. College St. Charlotte, NC 28202 - �Q/lawi - 2/29/2024
Pb�s roml;Address.C*,aid Zip SiErtattrrc of r .:ilicvl Wc1l Cmarartor ar'Wen Omer Dace
ttECKLENBURG 08002401 13y,rW Wrg this f-m I&rfeby certify dwr the wwell(sl was(wmi abnndrom-d in
Cosmty P=W tdenufizatkta No.(PR4) Qc4xn1 wx-,l'with IS f VAC 02r,6100 or 2C,02 0 WWI Cons air-Wto Randurds
and tknt a twpj,of&is retort har bersr prin4ded to ilia will o~r:
5h.Ladtudc and longitude in degrvWminutc%/% conds or decimal dtgrees:
,i!„d!fa:ld olk•hit ken.t. %181 9.Site diagram or additionalwc4l details:
You may use the back of taus page 10 provide additional will sib detains of well
N W abandonment detaib. You nmy also attach additional pages if necasan'.
CONSTRIt(TIOYDETAILSOFNNF1.1jS1BEIN(:ABA N DON FD C_UBAIMALINSTRUCT(t3NC
.Itkxh wrtl crins"citw rrtwrtkiii a!uiwlaO, F.v mulL•p1r r,ureUrne ur n,+rM.rtar wryly
is elb ONLY with the,snare c8 Lmutuaii,..bdW*'WM ar r.)Wl end s shmi aw,oft 10a. For All Webs Submit this form within 30 days of completion of well
6a.Wen CDik:TMW-4
abandonment to the fallowing-
Division of Water Roata Ces.information Processing Chit,
6b.Total*td depth: 25 (ft,) 1617 Man Sestior Center.Ralci;;h.NC 27699-1617
lob.For Infection Wells: In addition to seWing the form to the addtisss in 103
6e.Boreholedismicter:l (iti.l above.afro submit one cop% of this form Wilhin :)lots of Complexion of"'ell
abandorurtcnt to the,following:
Division of Water Resources,Underground Injection Control gram.
ad.Ai Ater Ics el belim Ernund wrtace: 20 ) 1636 Mail Serriee Center,Raleigh.NC 27699-16M
10e.For ater Cuarir&Iniectitin Wells: In addition to sending the fort to
6c.()titer Casing length of host n): 15 {ft) the addressles) above. also submit one copy of this farm within 10 days of
completion of%ell abandonment to the county health depattmtcis of the wunty
61'.inner casiDyftubin;;Ien;,nh(if Imussnl: (El•) where abandoned,
hg.Screen Icn1:th(if I.ri(mn):10 00
YMMOlA+•'ICY North Cambria Diel lmCua ofEmironmcni and Rrnzw AUDIO 2011