Mecklenburg_Well Abandonment_20240529 (2)

WELL ABANDONMENT RECORD for IUICONLY
This fonn can lie used for singk or olulliple wells
1.Well Codtramr Information:: WELL AgANDONNIFN I DFTAILS
Stefan Smith 7a.Number of wells being alwndoned: 1
Well C'ontimo r Naatc 101 Nell uN rct It vsanall, JUrd<naeL!Nc11011 IIAAWI praperIs i I u rNulaj h utjrat+rw .ir rru+-water >lq.fvl red. ONLY -eih !he'
r.:ncrrncb,.W,rha,Khwrxrtr.I.i(♦lNl tMh1Hlr c,w.-k.rpi
3576A
N('Wcll Cno%tiktOrCc.tifiwliou Niin#.cr 7h.Appmximtrte snlunar tat water rriaaia�g ar wdll%)2.4 1>:rl,l
SAEDACCO FOR WATIER SUPPLY WRLI S ONLY:
Conpam Name 7C.'1'N pe Of diMn(COAm n.ed:
2.W'dl Construction Penmk N:1000417, ,
I is.dj'r I.err,,if A)uwn
71. Nmtwnt of disinfectant uxd:
J.Well use(check;well uac1:
Water Cuppi%Will: 7c.Sealing materials used(check Al that apple):
❑Apricultural ❑%luntcrpal,Public f l New Cement Grntw M Rerwonne Chips or Pcllcts
❑(irnthcrmsl J1can»¢''C'oaAtnr tiuq*%1 ❑Rc%tdelwral Water Supph•(single) ❑ S;dnd('crtrcn Grout ❑Dn(U-.
❑hdustnal:C-onmicrcial ❑Rrudentud Watcr Supph•(sheted) ❑ConlcMIC Grotrt ❑ Dnll ClWmga
01mg3tion ❑ Spcemll�Grout ❑CMXCI
Non-W ater Supph Wed: ❑Betworute Suitor 1 Cltlter lexplain order 7g)
Nkhionlonng ❑Rcyoscn
Injectinn Well, X Far rich material elected shoic,prnsidc amimat of mater'lah 11W. 4.
❑Aquila Recharge ❑(inlurdwaier Renrtediation
❑Aquifer Storage and Recm en ❑Salnutt flamer
Bentonite.:391b ,Wtr:gal.
❑Aymfet Test ❑Stomtwalrr Uriuwgr —•
❑Expennnernial Ics:Iinrologs ❑Subsndeiwt:C'otwrul 7g,Praside a brief description of the araadunmcut prjwourc:
❑Geothenntal!Closed Loop) LITracer
Pour �.e...C-.+0....! if +.�.,a:t,
❑Ceothennal(Head +Cook Retum) L1C)therlC\ lam under'g I
MAY 9 M7a
4.Date well(%)amadoned: 4-26-24
Sa.1lI ell location: L
Metropolitan Redevelopment
I n <Mirr ti.nr. I'..,iPn
R.Certification:
1200 Metropolitan Ave, Charlotte, NC 28204 ems` 4/30/2024
Ph,sisal Address,C HN.and Zip c,i/�ran- ('enif>Ld Well Connactnr o,I Well(M_ Qaa
Mecklenburg IIy.r+),,yune this Jrwm, 1 hmby cert(!y dr+t the well(s) was tuerer ahantln ied In
C'aauo P_n,.t Ilklifitir.ni(u,N-, TI\, accunhowe wtdi 13.4.VC4C 01.0100 or:C ON)A•'rll C'crrstruc'toon.�7dnri4tn/.
and the o crpy of this recrwd has beery jwmvirl to the well owner.
ML Latitude and kinowk-in ok-grrmminute%tscicands or devimal dty;rres:
01 well fold ma Lit Wig i,wlrrciem1 9.Site diagram or additional%ell okiails:
You mas tisc the back,of this page t0 prm de addilwital well site details or%oCll
35.211639 N 80.836017 W ab:ndtitiomil details. 5 0ti toaN also attach Additional pages if nrec:tasan
S ONSTRUCTION DETAILS OF WELIASI KING ABANDONED SUHNIMAL INSTRut rtON
.H6xlr wr17 av+nrtru:aanr na„ra.v t!mwl,iak'. l.v mi,lftpjr uya•curm ru'run-ituar sYlyli'
a-rtl (MLY airh rhe iomian arhintltun'hrntr. boa. For All Wells: Submit this form within ;0 dins of completion of will
aN indonotcm In the following
Dhision of Water Resaatm.Information Processing Unit,
1617 Mail%mice Center,Raleigh.NC 27699-1617
6b,Tutal well ikpth: 29 (14.1
lqb, For Inhytion Wells: lit addiliai to beiding the fornt to the address in hla
+rc,FlonliolC diaaie(Cr:2 tin.► abuse-also stibnu r t rtic cqn of this form within to dass of completion of well
aharrlonnlenl Iu the tollounke
19.8 Division of W Ater Resources,Underground Injtytion Contnol Program,
(it[.W Ater k d below ,round surfatr- Al 1636 Slail Senice Ceater,Raleigh,NC 27699-16.M
lac.For Water Stualh A liflo'tilon Wells: lit addition to sending the form to
(K.Outer casing length lit kimra): 19 lft) Ilk addresslesi abo%e. :dso submit otte cop} of [his fomi within 11► dms of
completion of Ncll aband iunern to the counIN health,1cpannierw of the county
w licrc ahariclnrcd
U.Inner casim;+tahing length Iif laiawn►: (ft.1
6g.Screen length lit know a 1:15 A I
Fomr GW-lit Ro v"Atquu Yil t