Mecklenburg_Well Abandonment_20240814 (4)

WELL ABANDONMENT RECORD
This form can be used for shWie or tattltlplo stdb
1.Well Contractnr Information: \� WELL ABANPQNMFNT DF.TZI!_t
Robert Miller 7s.Number of"dis being shandoned: 2
WL It(ortnwtoi Natrc(or well owner penalalty:dsvrrtotrirrg well on hWher property) For wtdlhrle t)#"cvi er +grin wydar sWpty *Wb ONLY wit, IN,
cooaairowtwat aM&Aw +rwrnt,)Vv CM ar14mu ww-fiW+t.
2675
NC\Fe1S<(on�L+clnrfketijigtlplil�tm�Gr 7b.ApproxhuM a voYrme of water musining io we11(sk +cal.i
." - - - -
SAEDACCO YOR WAT1rR S[JPP1,Y WFI.t ONLY:
('.,nrpWrl fvanrc
7c Tr,x of disinfiYtant used:
2.Well Cbllattrctiou Pauk N;70002865
I.tst eli[ylpfkbir-WellPrrrnite o.t.(-tMM/,t'.Shure.I'irrJaWf.Inj&IMM ek I(1 Xj&JWr!
7d. �nwunt of diainfectaut used:
3.Well aw(shed-web tusr):
Water Suppts Well: 'c.Scaling milt a14 etilod(chock all that apply):
❑Agr"Itufal E3%I niclpalJP*hC x 'Ned Certtw GMW Cl Retitonite Chips or Pellets
❑Goothcrmal(HeahoWCooling Supply) DResidettiai Water:supply Cattgic) U Sand Cement Grout ❑Dry°Clay
0 tr4ustrial4Commercial OResdcmial Water Supph'(slia rod) ❑ Concrete Gratz ❑Drill Ctttiop
o ltfi lion ❑ Spfti*•Grout ❑ Coauri
Non-Water Supply Well: ❑ Mionite Shim' Cl Other(etpbta Under 7g)
MMomtonng 17Rezor<+ery
ujertion Well: 7f.For each nrater'iA selected abo+(•.pro%ide amauetof watteriaboad:
❑Aquifer Recharge, ❑GroundtcaterRcmcdiation Neat Cem. :941b ,Wtr:7gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Stmoge and 04coF% ❑SWindyBarrier
❑Aquifer Test ❑Storm%atcr Drainage —
❑Ex "imeutal Tochmlogy` ❑Subsidewe Control 7c•Primitic a brief description of the abandonment procedure:
l7Creothermal(Closed Loop) Mracef
Removed DPT tooling and grout abandoned boreholes
oc aothetmai oicafinfiEmblu.,RearmI 00dwi(explain under 7•)
4.Cho well(%)i andoneel:
Sa.Wen location:
Rimkus l:
Facilit%;CN4wrNarrc Fatelm IAAtifapplicabkl IL Certification:
2699 W. Sugar Crook Rd, Charlotte, NC 28262 7/25/2024
Pks-sical Address.Ci»,and Zip SejnMv. /y�:c•"—,.i+rner 1]Me
Macklenburg 04704113 By rWW#W this form, l hereby mr6h-Nmr the wegftj was Nem)ah(hndomW in
Casty' Panel ldeawihraiiinit No.(PEN) atcx rtlanct wah IIA XCAC 62C.010l.or 2C.A20 Well!'cutslrocbft Sbrmdar&
and that a coff ofdeis mrord Jaw bags provided to the Well miner:
Sb.JAMN&Sod lot l in dtRltt wends or dnimul do-Lrat
(ifarll(VK uiia bVIOnS is lent► 4.Site diagram or additional vrell detaRs:
You maN use lire back- of this page to prm ide additional well site details of weir
N -Vli abandonuu-tu detaih. You may also wash additional pages if nectssa».
CON`TRU(TION DETAILS OF!'EIdUS)BEING ABANDONED SUBM Al,tNCTRi1CTIO
:ttluctr wr/t cv�m+tryciturt rrcwrrltrt ilosvilubk. F•iv multtpir rna:ti+m ev nrrt-xuKr rur�+h
wells 0!V'LV*iA the s„t Ml Aft i0ft 10a. For All Welts: Submit this €orm %ithin 30 dty'3 of Co ion of%ell
6s.VVCU IDa•GW-1 a GW-2 abandontmcnt to the following'
M%isiun of Water Resources.infurmstion Processing Unit.
6b.Total well depth: 30 A) 1617 Mail Service Center.Rsleigh.NC 2769s14617
10b.For infection Wells: In sWition to sending the form to the addrass in 10a
ubosr.also submit one copy of this forth mithin 30 day s of completion of aril
Iic.R+trttnrlediamctcr;2.25" (ln.) abandonment to the following-
(�) Dhisionef WaterRciources,l ndcrxr+wnd InjectionConin,l ProUratu.
od.M Ater lcsel hckm Ground surface: 1636 Mail Service Center,Raleich,1C'276"-1636
Gc.Outer casino lcntRh of luioa n): ((�,) ik.For Water Suoafy& tn&•cti+m ells: In addition to sctdi4$the form to
the address(es) above. also submit one k:o,n' of this form within 30 day's of
comptction of sscil abasdonnicnt to the :oruty health depsrtmert of the County
bf.inner casin;,/tubinti IcnLKh Iit latns.nr: 25 where ibandoncd{ft.)
Screen lenI:tlr(if Limon):
Form K1Wy+y Nonh C arobta Depaatw"of Emironroent wed Nuiuml Resources-the nton of Wawa itesoun:cs Rer>sed Ate 200