Mecklenburg_Well Abandonment_20240814 (10)

WELL ABANDONMENT RECORD R,t Imaenul 1,"w ONI N'
This fonn can be used far single or nJdliple Wells
1.Ii1cll Crintracmir IMnrmation: Wrl.l.ABANDONMENT DMAIllS
Tyler Brown 7a.Number of wdls bring abandoned: 1
Well Cotarmit f Naar tof well owrrY pmonall} on hN lr•f proper%t r,w mxlvplr a ievowut .w ww-wafer arrpph cells ONLY with the dace
a lNl+flr(t Il,Nf,AF,J!F'h W MN,If,I.IN, IJI,Jl,111J:f,Nr• t.I'J1J
4625
N("tt`clt(.Lmn-"t„rCc"Ificalion Number 7h.Approximate%m ome or a attr rrnuining in%ell(s)9
SAEDACCO FOR W.ATFRStIPPIXN%FLLSONLV:
("Tivam Natttc 7c.'1'-,pc of di.tinfcctam used:
2.Well Consintctiue Perm%K:70003214, ,
!iv:dl,q.rdla vi,)„�11 per>tellr n.e.('wM.BLMr.l unune a brfea%Jun.r7c."!AlnJr.r
U.Amtrant of di.infiYtant u.ad:
3.Well a.e(check Well raft):
Water Saplily Well: 71L Scaling material.u.rd(cbmk all that apply):
❑Agmolmral ❑klunactpalrPublic ❑Nc.at(emem(inNtl M Benlonne Chips of I dictc
013"thcmLd(Ilcanns,<oolingSuWp 1 011midetttal Water Supph msinplci ❑ Salk](ctrreta(scan ❑ DrN Cla%
❑Ind isimil Conmicrcial ❑Rcsidctttnl Water Supph(shared! ❑Concrele Grout ❑ Drill Cnibngs
❑Ian^lknt ❑ Spa-ita y Groul ❑Gratd
Non-W ater%upplt Well: O Bertoelte Slum I 1 Other(explain under 7g)
IGhtolalonne ❑Rcto%en
lujectinn Well: 7f.Foreach material wl(rted ahotc,partitk afataintof ltmgteHabteed:
❑Agmter Rechmge ❑Ground%atrr Rentediation
❑Agmkr Storage and Recin en ❑Salmon Bamer
❑Aguiler Test 0Slor%tater Drainage
Bentonite.:251b ,Vtr:gal.
❑Espenment Il l cthnotogA ❑Stfisetierke Comtnl 7,1.Pro%ide a brief deNtriptlon of the abandonment pioct-du r:
OCKrothemral Wk-m-4 Lmipl UTracer
Used Bentonite 0'-25' for abandonment
C]Gcothennal/Head +Coolim Return) HOftric\plarn under T ) ----
4.111hettWg)SbM*tbtrfed. 7-19-24
3aWe.Ilrpll..: AUG 1 L. 2024
Perry's Market
Facilih^Clwrter Narfc I ,. (,. �tr ,n.,t,t,lJaalrkl li•Cet7i11ra1itm: ►C`_�::'l.i"`, a-r^i/si ,� �< 5.
6727 Wilgrove Mint Bill Rd. Mint Hill, NC 28227 7/19/2024
Ph,sisal Addmu,Cab,aid Zip S orele of Ceaifiad Well Contracian or WA Owner Dote
Mecklenburg By agnrng fetes fiar-tan, I hereby cernfi-raw the well(s) was/t►enei abandoned m
t'auta� Pafccl ktcamfication No.41"Mi akx-vnk###re win#I U XCAC 02C ,010)or 2C.0100 Yell C onstructron SYrsulf#rds
imd rhar a crlry of this record hair been IxrnwW to the well owner,
Sb.Ladtude and Inalitadc in dcgrtcalittitturewiseerrndr or dednal degmVia:
(Ifwell Filet mw Lit L,og r,"ffiwwral 9.Sitc diagram or additional well tlttapa:
You muo the the back of this page to prcA ide addincnwl well site derails or%ell
N W abardotunem details. Ymi#nay also atta•At addttwnal p pas if occessan.
CONSTRIAnON DETAILS OF W ELIASI BEING ABANDONED SURNIMAL[NSTRt1CT[Os
.I/ruch well menrdrs!{1 J11Whahic. hr J whiple agectim fir wa-viVier suppdt'
rrelk ONLY MJth the vtmr cwr.%?rW spur aN nnkwxarrlc few earn wAwll wre ktM.. 10a. Fair .All WeBi: Submit this fomi %xthin 0 dads of completion of%tell
6a.Well IDiI 8-g abandounicnf In the folb%ing
IN%Won of W Atrr Re.rnrre..Information Processing Unit.
6b.Vaal well depth: 25
1617 Nail Senice Certrr,Raleigh.SC 27699-1617
(fl.►
lob.For lnicclion W'dis: Im addition to setduog ilk fora%%to the address all ilia
abme-alw subout one cop- of this form%nbtn ail"s of completion of%tell
tee•Brrrrltole diaereter.1 (is.) abandoontacm to the folbttins,
Ditisloa of Water Revaurres,["ndergrttund Inj►Ytiun Crinlntl Program.
6d.W'atcrktel hrlttw ynrwal.urfaee: (ft•I 1636 Mail Senior Crater,Raleigh.NC 276"-1636
20 Inc.For Water Suntrh h E;& Inction N: In addition to sending the fort to
6r.Uuhrcasinxlengthldlaownl: (k.l the address(esi abote. also submit one cop} of flats form %"ithin to d:ns of
completion ol'%ell abandorancrit to the coum-, heahh department of the cotjnlh
%here Abir►doned
bf.inner ca.i»�'tobin�hen:-Kh tit banal n is (fl.)
fig,Screen lewoh(d(,rtoti rt t:5
Fort GW-.IA R y vied August:I)l(