Mecklenburg_Well Abandonment_20240423

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• WELL ABANDONMENT RECORD Cl\ArtmsmrlU:cONL1,
This form can be used for single or multiple wells . �
1,Well Contractor Information: WELL ABANDONMENT DETAILS
Brian Ewing 7a.Number of wells being abandoned: 1
wen to ndor Noise(or welt as ret p aotrali)alsindotring well on hic!ier piopcny) Far multiple Walton', .or rwriarefer supply %ells ONLY will) the some
C6rtntrrtCflomPlrorrdrinmerit,you cot submit!'rszefir7n,
4240-B •
NC Wd1 Con[mUorCarli0ic5tion Nnn#rc7 lit.Apprnzimatc volume of water remaining in well(s): ( ail
FOR WATER SUPPLY WELLS ONLY:
SAEDACCO
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit M:70003119, , -
List dl applhttle well p tri d&&(i.ec Cumrh:,Sue.,Parlance.brfertiou,•et fr;throw/ 7d.Adana of disinfectant used:
3.Well use(chcd:well,use): .
Water Supply Well: 7e.Sealing materials used(check all that apply):
DAgrieultitrat OMtinicipal/Public III Neat Cement Grout 0 flen1onitc Chips of Pellets
• °Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Said Ccntrnl Gtn it ❑Dry Clay .
❑IndristrialfComnrcicial ' ❑Rcsidenti:l Water Supply(shared) 0 ConcreteGrout. .❑Drill Cuttings
❑irrigation 171 Spec:ialtY Grout 0 Gravel
Non-Water Supply Welt: 0 Bentonite Slurry 0 Other(explain under 7g)
IMMui itorine . ❑Recovery
injection Well: . ` 71.For each material selected above,proside amount of:materlals used:
❑AquiferRecharge ❑GromnitaterRentediotion Neat Cem.:471b ,Wtr:3ga1. _ Sand Cem.:lb, ,Wtr:gal.
❑Aquifer Storage and Recovery ❑Salinity Battier
❑Ai)nifer Test ❑Slonimater Drainage
❑Experimeulal Technology ❑Subsidence Cotuml. 7g.Provide a brief description of the ahandnnmcnt procedural
❑Geothennal(Closed Loop) OTracer
TREMIE GROUTED FROM THE BOTTOM;.TO-THE SURFACE, .
❑Geothermal(Heating./Coolin£Return) ❑Other(explain under 7g) 5 .E k , . ...,
R..r ti i._ '
3-27-24 9rt
J.Date rcll(s).abandonccl: APR 2 [G24
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Sa Well location: . lRaiiFr. cic;: . •": �,� :N„�;-,.a I l,e#;
Retail Property • `�C- i O
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LV •
Facilit-/Owrn r Millie Facility IPA(iruppliwble) S.Certif ratio t:
' 4903 South Blvd..Charlotte, NC 28217 Brian. Ewi nag. 4/2/2024
Physical Address,City;and Zip • . Siummtne en or w corurdruor r s'e!l Orvn;r . Dim
Mecklenburg ; -- _ By signing this form, I hereby certify that the well(s) teas(were)abandoned ur
Count,' Darnel ldemiricitla t No.(PIN) ocxonhmce with I5.4 NCAC 02C,0100.or 2C.0200 i(%eILConsintctron Sttintkirds
and that a copy aphis record lots been provided to the well on-ncr.
Sb,LIDO]de and ltingittrde hi dcgrcr.sfminn[tcstscconds or decimal tiegr•ees: .
(if ssn rl d,one lhrikrns issirflir:lora) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well •
N W .abandoinnent details..You may also.attach additional pages if necessary_
CONSTRiiCPION DETAILS OF WELi S)BEING ABANDONED • s URMr1"1'Ai.INSTRUCTIONS - '
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:Math Veil coestruclierr rranrdfs)d available. liar multiple taiectiorr'ar run-avrla•supply '
melia ONLY with the sow rmcsernctwrr uharthrnrmvrr,i iu eau mbnift cure f'aaic 10a.Far All Wells: Submit this Conn within 30 days of completion of well
Ga.Well IDi:mr4-1
abandonment to the following:
Division of Water Resourets,Infotmmation-Processing Unit,
Gb.Total well depth: 25 • (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
IOb.For Injection Wells: In addition to sending the form t!)the address lu l0a
Gc.Borehole diameter:2 (i ,) abort.also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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Division of Water Resources,Underground Injection Control Program,
6d.Water level,bylaw ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6c Outer coxing length(if!mown): (ft) 1Oc.For Water-Snooty&infection;Wells: In addition to sending the form to
tim addresses) above. also submit one copy of this font! within 30 days of
completion of well abandonment Co the county health department of the county
GE.Inner casing/tuliing length(if In own): (ft) where abamdoncd, i
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6g.Screen length(if known): (ft.)
Fotni GW-30 Noeh Camtim Depetntcol ofEnvironmcnt are!Natural Resorr.•ccs-Division of water Resorucos Revised August 2013