Mecklenburg_Well Abandonment_20240529 (3)

WELL ABANDONMENT RECORD 1`11r111111CrM1UNONtY.
Tim,form can be used for single or multiple wells
1.Well Contr rater Information: W'F L.L ABAVDONNIENT DETAILS
Stefan Smith 7&Number ofNells being abandoned:
l
Hell Cotr<actar Nave for well rywaY pzrwnalfi a(urdonua Nell on Ms lier propitm) For wuffopk rn7eol„r rr .r: ,.,rr .,, ONLY rtn4 die seen
croVtslnratHrs aitarwhwtntrru.taw(,of IM uUr sot.klrm
3576A
NC Well CotamcttxCcrrlRcalba Nsnlscr
7h.Approximate vnimme of water remaining in wrll(slT2 Irat.)
SAEDACCO FOR WATERSUPPIA N%ELLSONLY:
Contpmy Name 7C.TN pe of disinfectant nsed:
2.W'cil CNatt,rctiun Pmnit M:1000417, ,
1 w;lie wv4,uhh•w•ef/+rr...... nn,.4hwe.I anwre.L ye'lir w,etc..rl Ain.rw
7d.Amrinnt of disinfectant used:
3.W'dl use(check well usel:
Water Supph Well; - 7e,Seating materials used(check all that apple):
❑Aprwniturd ❑MunicipalrPub4c f7 Neat Cement Grout M Acntonitc Cho or Pellets
06cothcmcd(Ncatuic-C•oohu Supph I ❑Rcsidrnttal Water Suhpi� t.ur 1. ❑Sand Cement Grunt ❑ Dn(ta..
❑hductnal.Commcmal ❑RcmdcntialWato Supph i,h:rrca 11 CaK7eteGrml ❑ Unit Cuttings
❑Ire uott ❑Spectalt}Grail ❑Gran el
Non-Water Supph Welt: U Bernoatte Slor'n U Chher(explain under 7g)
l9Motatonui ❑Reco%en
Injection Well: ?<For each material ackcted abitrc,prmidc anutunt of materials owd:
❑A4utler Recharge OGromdwcuet Rmttetttamm
❑Aquilor Storage and Recrnm ❑Salmi" (Barrio
Bentonite.:331b ,Wtr:gal.
DAymkr'1'rst OSlonmsarrr Ursitutve —.
❑Eymnmental Iechuolokn OSdisidetre C'oiarul 7g.Prmide a brief descriptitm of the abandonmcat pnwedure:
ClGcolhertal/Closed hoop► tlTracer
( , r
OGtttthcmwl(Nptin �t"lx�lio�Rsyom! f IOtticrlCc lam older'�I Pour i
i OttMwclltslatraudntxd_ 4-26-24
5a.W'ell hiCarion: x ,' J _.
Metropolitan Redevelopment
Facilm,ri„trr Name Facilm m.,i:q,I,1.;;rbk►
ti.Certification:
1200 Metropolitan Ave. Charlotte, NC 28204 4/30/2024
Ph,sical Address.Coy,and Zip We- Centf«ed Wen(bapacaw isr Wen(warr Dole
Mecklenburg By sagitung this form, 1 hereby cernA,than the wellfs) was(Were)ditwidaned in
C'oau) Pwd Wa dlimloti No.(PINI a(xanhtra-e with 114 NUAC A1(",A100 or 1C.0.V0 Well Crnnlivroon Staudt r/,s
and than a(vpy aJ(hiss imrird bar heeii privuidterl to the well owner.
51L Latitude and Inngitltdc in de rveominutrslscconds ordeclwal degrees:
ufwell field oik:Lit Ire_i,.,du_ -+a 9.Site diagram or additional well 4k4aAs:
You our, the the back of this page to pKnide additional well site details or well
35.211309 N 80.835742 W,
abatdot meta details. You may also mlach additional pages if necessan
C'ONSTRIY-HON DIET AILS OF WELLISI BEING ABANDONED SUBMITTAL,tNSTRUCTfONS
.Hui. :aiW ahk. Par multiple rnlec8rm ar rnn-xauT sujy.iv
n�r.t ahumk..«ea meyewaun wAmrr.ore Ionic l0a. For All WCIb: Suhmu Ihes farm wuhm +0 da-s of completon of well
bi.Weil I U=-
TMW-3 ah:ndounicnt to the following
Di%Won of Water Resatnrccti.,Information Procesang Unit,
61/.Total well depth: 24 tft.l 1617 Mail Service Center,Raleigh.M'2 7699-16 1 7
10b.For lnleclion Wells: [u aWilion to seidutg live fort to the address in l0a
abocc.also subnm orte col* of Ihes loon wnhtu zit dins of completion of well
t.c.RiirrMrlc dlariiMCr,2 (tn.l abudoumetu to the following.
y 12.35 Di%Won of Wafer Rewtuttes,Gnderuntund Injection Conlnll Program.
W.Water kstl below .rrtltrtd surfarr (Ih.) 1636 Mail Serniee Center,Raleigh.NC 27699-1636
9 lac.For Water� tih Di & I n d nject4in Wells: lit to sendng th
e form to
Cic.(later casing Length!if lanes at: (ft.) the address(esi above. also submit one cop} of this form nitltin ill dm s of
completom of well ahardmimcm to the cousin bailth dcpannieat of Ibe count
where ahar.1ti M
U.Inner casing.+ta hang length lif►imnwn): (ft.)
t.g.Screen length It(kwown1:1s (ft.)
Fi mi GW-in Nonh t'a..4un lklnnn>n of En,(moored aid Natw l Rcwu.tres Un tsntfl aI N'atrr R wtrta Re,Tied Augusi?oI t