Mecklenburg_Well Abandonment_20240814 (11)

WELL ABANDONMENT RECORD Far4gerre,llvC)NlP
This fond can lie used for singk of nniltiple wills
1.WrN f'nntracmr Information: M'El.l.ABANDONMENT DETAIt Sl
Tyler Brown 7a.Number of wills bcitq;abandoned: 1
Well t't-maciw Name row Moll oMnr pmaaa%ahaadtrnrag%ell on hi iker propen)I For trridnpA HnIftfsaw or newt-wtwer .xrpph wells ONLY with the smie
t wawrchoa aboa kwnaew,�rw Darr aalswtt tsar htnw.
4625
?b.Appratimak aobtme Kwater remainhtg im wdhsl0 )
NC Well CnraractnrCcnific,Ww,n Nwmhrr �
SAEDACCO MR WATIR SUPPLY WELLS ONLY:
Conipitn)Name 7c TMteetdhlrkttart used:
2.Wdl Coaatr9lctiou Pernk o-70003214, ,
fwtdl +;a4:ahle tael/lrrmtda me.( emn,NBwr.I;trtuwe ltrtet6urt ei, dkttrnrw 74.Ammmf of disinfectant used'_
3.Miell ww(check well vat):
A'Ater Cupld}Will; let Sealing materials awed(cheek all that apply):
❑Agricultural ❑Municipal; u C m
Public ❑ Neu Gina t M Rewrote Chas or Pellets
06cothemwl(Hcanng-Vooling Supph l ❑Rmtdcrttal Water Supph isinizici ❑Sand C•einew Cittnn ❑ Dn CIa%
❑Industrlal:(bmmcrcial ❑Rcaudctrtral Water Supph isluircd! ❑Cotu-rete Grout ❑ Drill Collings
❑Irri •ttuu ❑ Specuuln Grout ❑Gra%d
Non-Water Supply Well: ❑Ben tonne Slorr, U Other Ie\plain under 7g)
KNlotntontiv ❑Rccosen
Injection Well: X For each matrrial scle ted Ahoce,protide amiruet of materiahc tried:
❑Agmfer Reclunge ❑Groundwater Rentedtanon
❑Aquifer StorAge and RcLxn in ❑SaIInIIN Hamer
Bentonite.:251b ,Wtr:gal.
❑Aquifer Test ❑Stornmater Drauaiec _
❑Espenmental Tcchnob&% ❑Subsuktice Control Prrtt ide A brief drsr riptinn of the aibandonmcat prowedurr:
OGeothemial Wkased Loop► DTracer
Used Bentonite 0'-25' for abandonment
OGeotherirtal(Heaun 'Conlin Return) ❑Ottacr ita lawn under'�i —
4.Daft wvd(,.l ahandonvd: 7-19-24
Si Well hhcation:
Perry's Market �t v
Fxilrn(h,rtr Nawk Facilm I1>M tif:,t,t,ls,,hk) R•CcnilkadaMt: r :^any, �•
Ifs`.'^�:?�••
6727 Wilgrove Mint Hill Rd. Mint Hill, NC 28227 7/19/2024
Phs sical Address.CMS.,ad Zip Sit Mare of Centflod Wen CowAor or Wen Owrpr Date
Mecklenburg 1i1 sigu(rig th(.s36rm, I hertby cern,4-Afar the well(:)was(weret ahmarinned of
Cawur> Pmet kkatr6uiiw)n No.IPI`i occonlanre with IJ,I AcUAC 0X',0100 or X 0_V0 Well Com whon,Stonikinls
and deli(a ciryir ojtfia awned lau•beets prot•idted to tee well owner.
5b,Latitude and Inngihrde in degrevVininutes/w. conds or decimal degr+tm
Iifwcll fcM.on:Lr long i,.ni71c ,q+ 9.Site diagram or additional wc11 details:
You roar the the back of diis page to prm ide additional well site details or well
N —_ w' :tbandonniew details. You roan also MI&A additrorcrl pages if necessary
CONSTRUCTION DETAILS OF A ELUSi BEING ABANDONED SI BMUT.AL MSTRUMOWS
.(troth well trtarirawiuw trcnrd,v q lit wl,atk•. hw multiple enlettian ar wn-%,weer swfyh•
w-elkONLY with the samw tunmrrw(Ant ia4wnhuxnrnL itv tun srhwit rare•limn, Ilia. For .All Wells: Subinu this famq uithin 1,0 da)s of completion of ucll
6a.WeN[DM:B-4 ahatdminicm to the follm%ing
Di%ukrn of N'mr Resources,Information Processing Unit.
66,Total wall depth: 25 la 17 Mail Senice Center,,RAlriLh.NC 276MI-11617
Ift.1
lnh. For Iuieclion Wells: lit aMilk4i,o bending die fomr to the address tit lua
above.:kw suborn care c qn of this form within 30 days of completion of%%ell
h.c.Mircliolr diameter;1 (in.) abandonntew to the killowing
Disision-;f W ater Rrsuurccs,Underground Injection Coetrol P egram.
mil.W'atcr ksci helnw muviW W rfarc: 636 Mail Scnice Center,Rakigh,N('27699-1636
20 lac. For dater,Shoals & lniectitm WeRs: In addition to sending the fonn io
sic(lutcrcasin> Irrratlt of laownn I(t) Ilk, address(esi above. also sithimt otti: copy of this fomi within it dais of
completion of well Abanfoninent to the county health dcprinicn of the coups
6f.Inner carin>r+tnhioLkytyKh(if l:n(iwn): (ft.) w lure ahardoned
6g.Screen IcngIh(if knownl:5 (It.)
FotinGWAA1 Nt,nl�t':ui.luuDcp&nnicnefEn,ininsiwtglidN;iturtiRe.ouFces Re,KkdAtagust I;