Mecklenburg_Well Abandonment_20240814 (2)

WELL ABANDONMENT RECORD For lroemilVWONI X
This fonn can be used for single or multiply wells
1.Wril 0intracaur laturrratiou: WELL ABAN DON MFNT DETAIL ti
ROBERT MILLER 7a.Number of hells beings abanth(ned: 1
WC11 tbutwoor Nang(or viellovtoer personalh Amnde)lung Nctl 011 his leI propertm 1 Few multiple ayectiar ur rm,a-,w(er 3WpA toelLi ONLY wuh hlte iw-,
1'+Nlrf►tr(f71N1171ti1i1Ml�NNnenf.Wove Iff'NImiot'vir filcm
2675A
NC Wd1ConMuporCcrnific;iNmi Nnnftcr
7b.Apprnximate vnlrime of aatrr reireaining,io►+ell(>i): fRal.)
SAEDACCO FOR WATER SIIPPI.Y WFIASONI.Y:
Contptmt Name 7c.Type of di4ofertam used:
2.Well Constntctiun Pt4-mit M;50000079
I pa:dllgrrllrlahjr 4e'1:W".111 1 ' 11191 Nhde ll uriawv_hVetilOK etni 1/knnV 7
7d.Aruwat of di,inftYtrnt uxtil:
S.Well uW(cheek Well use):
Water Supply Well: 7e.Sealing material.U."(chick Al that apply):
❑Agricultural ❑MuntcgxdVt"tc ❑ Ncat Cement Groat 12 Writonite Chips or Pcikts
❑(eothermal McannW'Cooling StrpQl}"1 ❑Rcsidcntm d Water Supph tstngle) ElSaid Clement Grout ❑ Dty Clay
❑Industnal,Commercial ❑Residenital Water Supph (shared) ❑ CottcteleGrow ❑ DrillCutnngs
❑Iris •two ❑ Specialty Grout ❑ Gratel
Non-Water Supply We": U Flentomte Slum ❑Other(explain under 7g)
11INIontionng ❑Rocotrn
Injection Wes: 7f.For each material wkvtcd above,provide amovat of materials need:
El Aquifer Recharge ❑Grvund%%jtcr RCntedn ation
❑Aquifer Storage and Rectm en ❑Salnuty homer
❑AqutfmTest ❑SLorntaterDrainage Bentonite.:501b ,Wtr:ga:L.
❑Expcnmcuwl Tcchuob& ❑Subsndetice Control
71t•Prnridr i brief dr.cripttum Id the abandonment pnperdure:
❑Geoiberrrtal(Closed Loop) C]Ttacef
Once water sample collected,-pulled DPT tooling and
UGeotl►emral(Hcttinw'Ca�lio Return) LJOthcr(explain under 7 i _ _.
backfilled borehole w/ hydrated bentonite chips
4.D2tevsrolls)abari lard: 07/17/2024
ia.Well location:
Motiva Cost Center #100370
Cac1h1,'<nrixrNvtx LKI lily lDMiifa ii<ahlc) S.CertdBcadm:
101 W. Woodlawn Rd. Charlotte, NC 28217 L4`I`'" 7/17/2024
Ph,sisal Addmss.C1h.,i1e1 Zip SiggrMu'.�!"!,:, ;w.wS'C':r;c:��, i 'Clrkcxrte► Vale
MECKLENBURG 16903203 ay:smunW Mis•)<orm, I hembi,cern#Aw the wellfs) was twer+e)abandoned in
Coulrt) 11areel ldctoilsemmit No.(PIN) artwrmlant•e with I TA VC.-IC 0.0,01(1I1 or X-0.1(Ul Well Construction Sta ukmis
and that a copy of this rimord has been lunwded tv the well owner.
5b.Latitude and bnRitodc in dcWrv%,,minutrvv conds or decimal degi cs:
tifwall fstK oft tat:lollr 1„nB;cx 1f 1 9,Site diagram or additional wt•II detadc:
You ma% use the back of this page to pro►de additional sid site details or Weil
N µ' abardoontert detatb You"im almi attach additional popitt if nevi ssan
('ONSTRUCIFION DETAII-S OF WELUS)BEING ABANDONED SUBMITTAL,INSTRUCTION
Anac i well apnruuc-IN"mcnrl+tl a avuhAk- Fe.v multiple tntntinm(r mn•owier w174i
welitiONLY%iih the wmplr canvfreu(kut uAarnk/m,tenl_tun carp=limit+min bxxr 10a. For All Wcl6.- Submit Ihes form nithin -,0 da%-s of completion of►,ell
6a.Well Md:RCD-09 abaidoonicnt to the follonita,
Dhisiun of Water Remiurrm.Infurtoatittr PrrocrxsioU Unit.
6b,"filtil,irll depth: 29
1617 Mail Senior('enter,Rabb.NC 27W)-1617
IhJ
10b. For lnkylion -Aclis: In addi ion to sending the form w the addiess in Ina
6c,Biirrludr diattmeh•r;2.251, fin.) alone. a6o submit one c4► ,% of this form within 10 days of completion of►cell
ahatdonutcut to the following
Dhislos of Rater Rewurce%,('nderurlmind Injection Control Program.
6d.Water lilt el behm ground.urfacr_ (D•) L636 Mail Ncn ice( enter,Rrleigh,N('276"-1636
Inc. For Water Sgoob & Iniccta)n%cote: In addition►to sending the form to
br.Uutrr ca.iugt Icn�th tit Icnnh n): 25 ft.) the address(cai abo►e. also submit one copy of this form within 10 days of
complctuin of m►cil abandonment to the county ImcaHh department of the county"
a(of.Inner casin�'tubing[rn;,Kh lif la►mtn Ikrc ahandniuM1: M.1
6gS.Semen length(if knot,o 1;4'
ForumGW-list North Cm 1ouDeµliiuk:ofofEntlmmnent mid N:amalResoinees-DnissouofWaverR. ia"s Rc%eyedmigim1)1A