Mecklenburg_Well Abandonment_20240814 (3)

WELL ABANDONMENT RECORD Forlroerr„ilt-WON1N
�Tlnis fonn.in be used for single or nulliple wells
1.wen CantraMr Information: WFLL ABANDONMENT DVTAIl
ROBERT MILLER 7a.Number of wells being ahanduned: 1
Niel COurranor Nook lot K.11 os.cser perscuull.N alvvnrk,nrng wctl al hexllel properly i F„r rrnrlopic ovecrwn ur Harr-w(ter swppA, welk O%'/.1 o)) 1"&.
r..r,+frM 0,41,x4u,xhurnn•nr.p,r,"Ur r&Nwr,war firm
2675A
NC Wclt ConitxlorCenlficaliou Number 71).Appm%itnate vuhrnte of water rt asinning in fiell(s): IgaO
SAEDACCO FOR WATER CIIPPI.V WFI.t SONLY:
Conpwn Name 7c.T%lte of disinfectant used:
2.Well Canstn mion Permit 0:50000079�
LurcdlcrpfJkuhh•wellJvrmrlr,r,e t uwrrr,..Vok.1,rnar v.ItyectMn,eA•.1ffkmwe
ld.Annouat of disiaf►Ytanl uxJ:
3.W'dl use(dicekwell use):
Water Supply Well: 7c.Sealing materials u..cd lchkrl all that apply 1:
❑Agncultiand ❑Munictp I:Ptlblic Cl NcW Ccmctit Grout (R Bcnionne Chaps or Pellets
O(kotherrnal McanngI'usding Sappl)i ORestdcrnud%Vater Supph isinglc) O Sand Cetneta Grout ❑ Dry Cle}
❑Industrial Commercial ❑Resukteial Water Supph isharedl ❑ Cotnctete Grout ❑ Drill Cuttings
❑Im •Uol, ❑ Specials} Grout ❑ Gravel
Naa-Water"trpply NN01. Li BentowleSlum ❑ Other 4 explain under'tg)
I>IMunitonne ❑Rn oven
njectinn%ell: X For each rtimerial t1 kv"above.provide amount of material.ttscd:
❑Aginter Recharge ❑Groundxvarer Rcnietluulon
L7Agmfer Slotttge and Rernven ❑Saluun Banter
❑Aquifer Test ❑Sronmsatcr Drunagc Sentonite.:501b ,Wtr:ga:__
❑EVennnenurl Technolokv ❑Subsidetwe C'onlnl 7g.Pmide a hrief description,d the ahandunmcnt procedurr:
❑Geotbennal(Closed Loop) ❑Tracer
Once water sample collected, pulled DPT tooling and
t�Geothettttal eHeati tC'oali Return) OUdleri sin under 7 ) --
backfilled borehole w/ hydrated bentonite chips
4.Date vents)ahandnned: 07/18/2024
5a.Well location: `'v t 4" ' i )^i.•
Motiva Cost Center #100370 AUG1 G, 024
rd 1111%(h%) v N;uoe Facility IDw cif applicahlcl K•(l'1't 1l ll'i1111N1:
101 W. Woodlawn Rd. Charlotte, NC 28217 �yC � • `j,�/c'L _jk;Y37/ 8/Z024
PMsical Addac$.Clt,.and Zu Dote
MECKLENBURG 16903203 Bj•.vjgWr4e flies Dorm. I hereby certify Am the welifsl was(were) ahasadwed in
('Dual, i'.1 ;Ici,•fairle3tion No (PP41 acrordom-e with I fA A'(AC 0X7.0100 or:C 02W Mdl C amvh dlo n Standards
and dud u cape of dris rerxwd has Item proved d to the well ticker.
Sh.Latitude and Ian&v4k-in rk>trcvlmimttrs,xcunds ur devirtral degrees:
Iifwcll fcl&roe la0ang r+rrlrurc,ul 4.Slit diitcram or additional well r tads:
You Intl, me Ilse back of this page to pro uk addilion:d%ell site details or sell
N w' abandonute►u detail You ulay also smooch additional pages if n eceylan
CONSTRUCTION DETAILS OF W MASI BRING ABANDONED St'BMt7TAI.INSTRUCTIONS
lttrxfi wrtl cvnarinreirun rncr.,nf•sr it,nwl.a5k. l•i,u•wmkipde elyrcnrsrr ry rrrn-wwler saaptth
wr1Lr O!Yl t'with the same cwrsrm rr nr uM1uwe/unwrcru.)ua con whnrrt cure timer. Ina. For All W'clls: Suhnal dos tame a Itlun ;0 days of completion of uell
6111,Wed ID#.RCD-13 .Ihandounicnt 10 the folltnving
Dirisian of Water Resorrce,.Information Pr-ucirming Unit.
tfb.Total well dciNh: 35 (ft.)
1617 Mail Senice('cater,Raleigh,NC 176"-1617
Inb.for tniccrion %%0lb. In addition to sending the font to the address in l0a
(ic,BnnludrJiamthr;2.25" aline. also submit ork copy of this fonn sstlhin 70 days cif completion of uell
(in.) abatdonmew to the following
Divisit►a of Water Resources,(ndetimund In jection Coat rul Program,
bd.Water ly el hrinw grvrund wrfaec: (D.) 1636 Mail San ice Ucotcr.Raleigh,N('276"-1636
Ink. For Water Sunnh Sc Inicctir a In addition to sending the fonn to
be.(later casing Icnrth cif Imow nl: 31 oft.) the address(es) above. also sulmir oue cope of this font within 10 daYs of
completion of ndl abandonnetu to the coatuv health deptmrrlena of the Conroy
6f.loner easin-_,,'tubing lenLrth(if Mmsni: fft.l lvhcrc abandoned
61,Screen length(if Wiorsn 1:4 A)
Form GW-jot NoalCarohm Deparmrn of Em ironmero ad Nanwal Resources-Dtststoaof Werner R.sourccs Rcr esed Amply.itl t

W L L L A 1J A LN V V 1N 1VJ E t1 1 K L L V K U I For Internal Use ONLY: I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Markus MacNamara 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4646-B wells abandoned:15
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Redox Tech LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit a: 70001346, W10300524
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7c.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public A Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) Li Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) D Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout D Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
DMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
OAquifer Recharge eGroundwaterRemediation -40 GAL NEAT CEMENT
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
DGeothermal(Closed Loop) ❑Tracer
Tremie grouted under pressure from bottom of borehole.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
4.Date well(s)abandoned: 7/26/2024 _
59.Well location:
Kinder Morgan Charlotte Terminal#3 AUG I
Facility/Owner Name Facility ID#(if applicable) 8.Cer t cat'
7325 Old Mt Holly Rd, Charlotte NC, 28214 D,V'4-;-0$/01/2024
Physical Address,City,and Zip SigWe ertified Well Contractor or Well Owner Date
Mecklenburg 0572120
By signing this form, /hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.276595 N -80.927854 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL LNSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• I PO - I P 15 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 19 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.25 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: NA (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) 10c.For Water Suooly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6C Inner casing/tubing length(if known): NA (ft.) abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 Nonh Carolina Department of finvironmenlal Quality-Division of Water Resources Revised 2-22-2016