Mecklenburg_Well Abandonment_20240507

:WELL ABANDONMENT RECORD: Foe n1cn l i35z•t2NL4 z .
This fortis cao be usedTor si k ar itiuit** Us 6.k
t•.WWcfi nntr.irt4rZnfvrmatton " 'FTLLABANDONMENTAFTAII _
Stefan smith 7a Namhcroirii llsbcln abandiiiikei 1
Weit•Coi caarNa (nracIto ncrp�notrafly tl>�minntna\loJ..... .1�'+rll rpra1TC33f). '- f`Ci� vtt 1e inft .6.,. ca_ rawiyoq..i 3irfp »eflr,-,. .• - -with dr..•,•a
.• •. : fdNF UVOB.'1[At, i n CY1�S:110rr�t.t7Vrd�O tr :
tnrctr�rit ineni
3576A.
'7b Apprrnalm,utc;'O4unf titu4er rem.umng an abdl fz)>2 i. :ij.)
NC WcU coitoocir C7eitif foBoio..4 40 . •
SAEDACCO . , 17ORWA1ERS.VIPP4X,\Mt;,$ONLY.... :.. • -
Co,i mi}=i3auto' `7c,Ts •.....of di ontettaut used
• 2 l SYcl Ctrnstn elion Pc inli !:7.00032OO;r. ,
Lttf titiON11 d.p a'n401i e Coi o.giii rot uurca li:te ior.e 1 tl,t!wwir 74.A noitnt ar cllsinfcetant.vsivi. :
3 Wdl tisr(chcctc*lt uiic}.
'Watersuppli Weil '7c gealinguutterialsused(,he dkalltbotapplt)
f7Agrcctilfn t i7hlimrcipifii'tibiic :D C bipsorP lets
'att�entent Crtuitt Hcntontte
t7Geoliiermni(I3'catin Cooku S , t�) Cfllesid ntul t 'Mer u l (silyi.) a Sand C.c* ent Grout: D Dty CL►y�
f� fi gip• PP y b
DliidtirliiaLf!~otiniIccc4hi: OA--''dantutl lVnf¢r Suppis(siyund} U Concrete Gaunt: [7 Dnil Cnttin `
Cllhir:itiati s -" .- [7 Speciait%Glom:- A,':Gra el
)4on WatcrSuppl3 Well •
Ii lenxv.tute Slrn)y.:: O'Otlier(ex•phtttunder7,g) '
StvidnI cynnr> i7Reciwei t: • -
lnjCctpdn.W�dit • r.cacltittatcrtal sc1Ccted abovCy provide ii.nollltl tlt•,flisiteri*tiSed:
7£Fo
CDAquif i.Itecltsrgc tiOiiitutdnatcr Re'uttdtation , • •• • • ..._ .
❑Agtkit is Sb4,,nod)(ei.O Ci)'> DSAitntta Damcr
DAqutfer lest US{p.....jprnriu c , t3entonite :1501b ,Wtr 5ga1
C]Eap.K iitentat Tc llttofogy OSitUsutcitee Coistrski' ,.7g Piiitidc a brief dci nrtion ortiie absindunmetf proedun,
C1Gt othcttnal(Ciosed Loop) »Tracer .
Temp.well for grab sample then i•:•-
ed ately:abandoned .
1ZJGeotfie'tnyal tl�•e idns�`Coelin.06wm} .11fhhef 0-0--Igh under 7 ., •
'4 Datiiidit(s)abandoned:•4-26-24 ' '''-.k,;C, r. 'V 1.r 7 '
.
':54.18'cl location; . . ..MAY :C i 2024' .
Yuntersville.Site
8 Certification ►r1;u rr.,c c Z? ,r,r�tic,. u;;
tiGttiliilf:* 140itp ••F. li tp•t f-.pptxstbic) , J D'Sc'Q`30-C3
11855'Mt Holly-Huntersville Rd., Huntersville, NC: ; 14 • g 4/26/2024
w
Pk} ieal:Address;.Clity,•andZijr. • •• • •• • • •• • • ' "lure, ces r1aWe4Coiufct.tn�rot 4ellOnm:r t) e
Mecklenburg 01720305 : <,By,tigirlrig this frinur I If.frOy ct.�rtifs rlwi the',el/(s :inns{ivere}abandoned tn.
f aprtly f'ariel iii iatttiaU nNo t,Pt4i acuehrlr,:ee to?(jr l of V C AC62C 0100 ur2C 02011)roll hslrntttoxr S'rcmdard
,, and thraia ccrpy>oftlitrrccrird has been prat i2l41 to the ucll tniRvr: .
' 5b.Latttude.and:tongs(adepn dcgt+ccslntinutc lcvcoyidaordecim,at dcy r.v.c. .
e iti rain ui ddditlo iatsh. ¢iits,cifltau,r� t „ � iiuer>t 9 Sdl hniell d e tails
eadnaei t detals oft llYouray usethe ba.ci ofpa, etoprovddto : sei
80'.854172 • WY :abutidoninentdeais You.in aopttuehadiittnnalpgfne iy COAS'CRIICTION Dr rAiI S OP•WEt 'ISI'BEING AflANDONED 6IURMIT rAT JNSTIWCTtO(S
tttotlr+trlf ru»sir tarn mtk,r4. Ifava•lto,5/e Tw tndiiple u kctuxr rJ)"n ii;i0jtu`suJ,liv
ii ifs 0,\14t'n i h flat Din cxrr air et 4k cn,rJ4rtrraprty,}�rt,Carr u/I 0ltr�tsrrd, l..
, . .. . . , . ,.. . _.`10.i.;itnr All iPiitc Stiiiliiti tti�.0 fctrni iri►tiiit 30 dJs of rpmplc{tiia';tif Hill
6::.W'Veti'IDk TMW-i . . ::abandonment to:isle follotrini . •
Aisisi in of iVilf0rlicstrutYv ,ln£ntYnattoq roct�scing;UaiY,
" 1617 ti�ed Seniu Cutter ltaiciy h.??C 276'J9.16I r:.
6b titt��rodt aeptb (rt;):
lt}ti rorbileetiiiit\Vetii '.In taddition to scixttitg thofonii to itiye fdteas iu.W0a:
'abov titso 3ubiiiit cite Copt'of tins fotvt►atlttn.30 days 8£complettOit of�t'ell"
e
'fir.Beriehole dl imcttrr:2- : (na)*" . :;atidndoyitnciit to the follot In, .
Di yisiott rr£WYater)itesouict ,TJndeaXropnd Injeetlou Garitoi.Proitraas
bd.Water tcrd beloss ground curfacc.43 •(ft,) ''. ,143d 1liatt Service Center,Raicigb,1sC 276991636. ,
,11k Fnr.l ider.'imnit&:inieetiiin Wttic .III"additton to sendg tiyc form io::
• 6e Outer casing lengtis(if lutottn). 30 (ft).' he. .t 'idd ess(es) .itsos a also i nut:one topy of Iles•'foam wit inhin 34 thtys of
;t:ontpiction of Hell ab*tmkinment lo-tbe couin li aids deputtnic if of tbc`entuth
6r lnnertacing/uibing length(if hntiun) • (lf j
6g Screen1cnjtbti£lmosr y)i 2a• I
• • (ft) •
FomiaWaU NanaCuroilm••UD•csitil it ol'.*viroiimenta1111•tnituatlta•sone•cs' tTiviskinoe:W'itcrkcsoivir.ss 1lcvised,Autiii'N 3;'
{

WELL ABANDONMENT RECORD;. 'Farlydlinrtt39gOTvL1'C { .:
'1tis form can be uszdf'or sii tle•pr multiple wells
"I Wct1Contr,ietorInfoimation • ;W11t,ti.A8ANDONMtNTI)FTAIe
Stefan Smith' • • • •• • 7ii vumbel.6(4e Is.hatng abandoned 1.
:8.:iii Cot radorh'amc 05i.4 It 4%%ucr p icinatl)1Wti inmg w-eZ nn tttalia,:rpr epein ) • t O' mIth4 k )10,..ett ar ra. ,trn tuft Cupp!} weIL ,ONLY '•ivi h th•e'••'•:s.46 .
nfrr tit i`Ofr rGQ�t1�u'.t'iil,rur CStrrt.r' 'tftr(N'rB ffJPt
3576A 1. 1
=7b AppinYitnd' alumuofHatt rom.nnmgii i'iaiok? {l± )
.SAEDACCO _.., •... . . . ,, X' 1t1YATERSU
Coii i.iif:Natiii' • 7c'Ctpt Of dLanfixt.tnt used
'.2 Wel cunstntetlon Permit# 70003200,. , , .
4itit,9 7ji fie ih4 1/00.nt1ti•44 C,.0. i Str�r`c 1'ur tiii. liti. 1.4r4*41/.tnciun; • '.
: . • .:.. .. , .... . . : . _ 7d �lttionnt of disinfectant used. ��•
. . •3 Wdt list(check�rctt u,<e),'" • • • ..
-WaterSuppl,.Well, 0:01 all t hat apply
•
'Je Scaling materials used(cat
I3A ricultuml. l]mfinrc 0.UPubt t3 N64Cettaent Grout b3 13entQ 11e•Cbrps oPUiets
•: clCYcothermnt(ltcatinr/Coohn¢Sugph) DFtesrdeutial•Water„uppt (stitT,lc) D Sand:Cetnent:Gmut. ifi Dr}CiAt
p Concrete Giant . . D Drill Cuttin '.
t7tndiistrittl.'Cniniiic►�,at'• _fJRtsidcnti:21\Vufcr.�'ttppl�(shnred} ,, �:
mtiriMition : • '❑Specaiilty Gruai:. 00*1
'iron WaterSupply Well >;
` 1�Hentautte*.r1r-: GI.Otater.(ei$pl�tnunder7i1;• .
>iiihfonitoruig ER i"'-' c.'-' . .
7f:Foreachma•t•erialselectedabove.priovidcamnunt:ofmatet alsused ;.
DA infra ttethsrae ifGiOii lsrwterl 4n04dioa
DAgtnfer Stott 6.i..ri 1 .o ciy DSaatndc Batricr
t ;Bentonite :1501b ,Wtr. 5ga1,: -:
taA40i4.r cst • L1Sfonli S.IiterDrul>i,3 : .
❑•l+. rtentel`Tithikiiag%. . •RSubsideac a•Coln,1 • -.Tg Pre l&a brief description oftlie abaaduament lrrrocudune:'.:.
DGeotltermal(Closed Loon) mTracer. .
Temp well for grab.sample then immediately. abandoned
: DGcothetmaltF7 till aohmtlteinm).. tiOtlier(eiipJainunder7iti• ...
A Datc.welCs)abaud•flned; 4-26-24
. -
Sd.1.Ycf location:,
Huntersville.Site $ C tr i 'ir a :::y�tJuS7;-: :U J2
.'r 'lii/01-*s crttc Y o i u}#(rru pi l 14?:• crtiticatlan C ic
11855 Mt. .Holly-Huntersville Rd.;. Huntersville, NC. r fie, Cit1' WC �rto �filti : .. )4/26/2024
PlnstealAddress�cii iidZip . • • • • • ' .:,
,
•
Mecklenburg" • 01720305 lly*i,�irIin this fdrrrix IWeriebp 641 shot ilre irel4a,)isas fireie)ab0nda1ted trt•
.otifi ' Panel'Id iiilft iiifiSnNo PiN) 'acci+►rkthce lrtth 1:, X'C t C 02C fill g ar'rC.02011 ZCt1J C,nsir aott.�Yandkard.
• r
nntlllrcu�cdp)Fo,J'tluxrecurtllurs brzi�nlarur r In Are tt�clt ms lies:
5b.Uatthrdcand`innud0indet+clminacscondor dxmta dgt ce,
-: tltiro .11. Ol iiik,:ii 00.tea : 9Stc ditgam a addoalwll das
'?on may rise tire•: ee).of Ibis page t o pro'ide additional well site detaits-or ri ll'
35_.384861: N': 80',8S4533 W • ab ytotn ntdetaili. You-iva}alga:attach:.midi iu?nalyag afne essar�f,.: • "
•
C(1tm7'Rtieriii,:uli`rAIt ti OF.WPLUSI Biitrt "ABANDONED ;AI1BMITTAI.1NSTRUCTIOI{S
thesis aw�P rnnatrazytau et.mrd[i if aysrilabk fur multiple inJerti�ur t4 taun?n�tttr .0.41 ., . - .
. -ii.cokii,�'L'1 ahlthdxr S rri cYiN.YrY:�ettOti=ti>iulr u"rthr�y,larh�e�tt d4 .c..0 ja.,rt. `loki or All.'4Vi�t1s Subiiu( tins`(aim within 30 gaits of cpmpietitin�ofh ell
• abando
6a,VelfiDtk TMW-2
nment to the f.614*T,
Diuiion4t\Vatcr Resources,Information.Frocesteng Unit,,,
•
4617 Matt ficrvrCi,Goiter Iliilecutr.hC276h)IGI7.: .
6b 7Aeti etc depw 4 •• - • 0)..:::-
. • lOb padXnectlonWes Jn oddition to seiidattgtWliinx ot6e address uyI04::
?uboc,alo sbmit oncoeotiics arm �it 3G cs of cpiecmrtpwll
GcL10 hole dl�tneterr'2 u r.e r
atsandonirntttieCollotkig ..•
43 . Dyson of Water iiesouirces f;Undcrgniund In jection Control 0.30.am,
•6d.Water teci bcloss grvmund surface (ft,) .• I,G36 M.ii Se vlec_Center,ltalctgb,NC.27619163G. .
IDe Far Water.•SJinnit*7oleetinn WeDw:an addition to.sending the fontnto
Ge4Outercasing.lengtlslifltnoao):28 (fc)•
: °:itta address(es) ntio�e, also subnut:one eop of this=loan within 30 da)s of"'
. ::ctrntpletioti of well abandonment Jrobthe cvo441t ttttt deprrtincnt of the+.coiintY•
6f 1'nni:rtt nanfittnbing ten th(if hncmn) : : (ft)
niwrc i>aandoted:. I
•
6creeit length(if ImoYw'n) 15:- (ft.)
;.S ,
Farm(IW O:" Noflh acothtu;Ucpmnnrni of E•nriiontuent mad,3lattuatItcsou ca t)htitonof WateiRe$o,gns: Reused iluem*2Qt3;
1 I .. '

t WELL ABANDONMENT RECORD
' North Carolina Department of Environment and Natural Resources-Division of Water Quality
....47.0.700,
a'" ®'' WELL CONTRACTOR CERTIFICATION# 4169-B I •
1
1.WELL CONTRACTOR: 5. WELL DETAILS: 1 ,
Roy Charles Killian,Jr. a.Total Depth 110 ft. Diameter:6 in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): 15 ft.
Summit Measuring point is -1 ft.above land surface.
Well Contractor Company Name
10121 Pineville Distribution St 6. CASING: . Length Diameter
Street Address
Pineville NC 28134 a.Casing Depth(if known): 83 ft. 6 in.
City or Town State Zip Code b.Casing Removed: s ft. 6 in.
i
(980 ) 581-7105 7. DISINFECTION: 12 oz
Area code Phone number
(Amount of 65%75%calcium hypochlorite used)
2.WELL INFORMATION:
8. SEALING MATERIAL: '
SITE WELL ID# (if applicable)
Neat Cement ?i Sand Cement
STATE WELL PERMIT# (if applicable)
Cement Ibi Cement lb.
COUNTY WELL PERMIT #(if applicable) Water gal. Water gal.
Bentonite ----.1
DWQ or OTHER PERMIT #(if applicable) r..,'' "- ' .`-� p ',�.,_' •%
•
Bentonite lb'.
WELL USE (Check applicable use): Monitoring ,/ Residential r C�24
Type:] Slurry I Pellets MAY tl
_ M unicipal/Public 1 Industrial/Commercial _.I Agricultural Water gal.
Irr`orr-:•,i;E P •-rC 5vit Wit
Recovery Injection Irrigation Other D, •' '3O G
— Other(list use) Type material 20%Solids Bentonite Grout
Amount 140 Gallons'
3.WELL LOCATION:
COUNTY Mecklenburg QUADRANGLE NAME
NEAREST TOWN: Charlotte 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Pin 11101102 Plaza Rd Ext. RentnnitR grout was placed into the well from the viirfar.e via 7"
treemie pipe.The well was completely filled with approximately
(StreetiRoad Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) 140 gals.A 6"concrete plug was placed over the abandoned well.
TOPOGRAPHC/LAND SETTING:
,/Slope I Valley ._ Flat Ridge_l Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of tlssell on the back of this
form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE 35 ° 15 , 32.4700 "DMS OR 3X.XXXXXXXX)OD in the well,gravel interval:intervals of casing perforations,and depths and
LONGITUDE 80 -40 ' 30.0500 DM5 OR 7X.XXXXXXXXVD types of fill materials,sed
Latitude/longitude source: 91GPS pTopographic map
(location of well must be shown on a USGS topo map andattached to 11. DATE WELL ABANDONED 5/1/24
this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
4a.FACILITY-The name of the business where the well is located.Complete 4a+ THIS RECORD HAS BEEN PBVIDED TO THE WELL OWNER.
(If a residential well,skip 4a;complete 4b,well owner information only.)
FACILITY ID# (if applicable) w g. 5/2/24
NAME OF FACILITY SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must be an individual wbersonall)ebandons his/her residential well
in accordance with 15A NCAC 2C.0113.)
4b.CONTACT PERSONNVELL OWNER: Roy Charles Killian Jr.
NAME Jarred Barr '
2649 Brekonridge Centre Drive Monroe,NC 28110 PRINTED NAME OF PERSON ABANDONING THE WELL
reon
STREET ADDRESS g
)Submit a`copy to the owner and the-orlglnal to u ivislon( Quality a Information Proces_sl g,f" Form GW-30
161lt7 Mail Seel IcerrenferslRaletgh NC 2r7699 61'7ohon-'�P (919);807-6300 . • Rev.5/10

401:
Capped with a 6" thick concrete plug
74 ft of 6" Steel
Casing, With a
total depth of
110 ft filled with
a 20% solids
bentonite grout
approximately
140 gals.
Figure 1 Villages Reedy Creek
Well Well Abandonment
Abandonment
Diagram SUMMIT
10121 Pineville Distribution St
Pineville,NC 28134
SCALE: NTS
SUMMIT Project No.: A23117.01427.000