Mecklenburg_Well Abandonment_20240903 (2)

WELL ABANDONMENT RECORD For leaerrtnl Use ONLY-
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ARAKR= T DICTA"
Tyler Brown 7a.Number of v ells be!"abandaned: l
Well Coauxior None(or well oviw petsonall)abandoning well on hi&%u property) Fter n kftlple inhft,r(wI tv nrm-wnwr apwily wwh OIMLY lath lire; Now
COMOWn,Nt-'Uhiila*-'-Newel,wo Cwr.VuAwt r nf,,r►M.
4625A
NC Well Cordmtror Cenirk*tiort Number 7b.Apptvxknt►tt volume of w atrr rcenaiuhttg to rtdl(x)? 5 t gal.)
SARDACCO FOR WATICR SUPPLY WELLS ONLY:
Compam-Naar 7e.Type of dWofet'taat used:
2.Well Contraction Perak IF:, UkTINO-3143/Incident$7079,
1.W 44l applbMbkxellFOrttutx(i.t_C:* y,Slate.Iarinwr•G"alit rk.!if AMAON 7d.AttMMI of di.infivtant UWd:
3.Well use(cbeck well u%c):
Water Supply Well: 7e.Sealing materials used tchecf,all that apply):
DAgrkultural ONItinicipaLTubla M Nnat 4`retttent Gmul 0 Aenronkc Chips or rcl crs
OGaothennal ftatingr'Cooling Supply). ORcsidctaiai Water Supply(single) 17 SW CrtncM C310tu ❑Dty Clay
❑bdttsaiWCklmmeecial ❑Rcsidcrwal Water Supply ijiluurd) O Conte Grout ❑Drill CuMaga
Olffigation 0Specialty r;roull Q Gin'd
roll-Water Suppy Well: O Bentowle Slum' O Other(explain under'g)
Mhlunnoring ORaot ea
Injection Well: XFor rack material.elected Aim v.prinide amount of material.used:
❑AgttifcxRecharge OGrotttdvtvcrRemedianon Neat Cem. :941b ,Wtr:8gal. Sand Cem. :lb ,Wtr:gal.
OAwtier Stooge and Rccvt cry ❑Sint.Bamcr
❑Aquifer Test OStorm%ver Dredge --
OExpertmetttalT&Imiogy OSubudence Control 7g.Prmitie a brief description er the abandonment proccdun•:
OGeothemral(Cowes Loop) OTrmr
OGeothermal(Heati �ooli gReturn) 00dwr(c+ lainunder7 ) tremie grout from the bottom up
4.Dole WeR(a)abaodoned: 8-9-24
Sw.Wtu location: p
Rimtrax Corporation Site
Facilif):Onm-rName Fact3it tI)N(ifappdrablt:) 8.CerdlicadIon;
10701 Reamee Rd. Charlotte, NC 28269 _
8/9/2024
PMsieal Addecss.Ciro,and Zip S ol+uc of t Ztt*d Wets C07LLti AOF or Wen Owaee Doe
Mecklenburg_ $V mgnLV Ihiv/Ivw4 1 hesieb),cw4 duv the welljs;l was 1> )alrnuuAwied in
pxcel ldeMMatkm No.(PiN) areon*wr hill MA A'C.1iC 62C'.4100 or X,02M IFrll Const vemon Shards
and Ome a cryit=q(&r record iku he•e>t ro. l to dr well owner._
ib.Latitude and longitude in drgrvxslmInut lsemods or decimal degrees:
tifudl r"rk1 one LivlmW n.ufficni tl 9.Site diagram or additional well detalh:
You may use the bad of this page to pw%xle aMtioaal%xil site demob or Aeli
N W' abandornnent details. You tnav a18o atutch additional pages if necesmy.
CONSMMOIN DETAiI..tS OF WELIA)BEtN1G ABANDONED SUOMiTTAL INiSTRUCT1ONS
Al4x*well cvtarirramn rrcurtMo it tnwlalrk. .Par tenlrtpk uVeafent+v rkm•svd�ir setppl}'
mill ONLY with the wine kwtw crwtt obood.awenouw to&. For All Walls: Submit this form within 30 dayt of completion of well
6A.We#IM•MN-2R :thandonmctu to the followiq-.
Diviskin of Water Rewur c%.Information Proceming Unit.
61r.Total w•!1 depth;1 18.5 ft.) ery 1617 Mail Sice Center.Idaleigh.NC 27699-1617
:
10b.For Inlectlas Web : To WOW to,seatding ft form 10 the address in 10a
i>c.Rt�n•ia�ir diameter:z ()a.) abo,,v.also submit one eoM of tint form within 30 days of etmtpledion of utH
abandonment to the follouing�
Dhision of Water Resources,tindergrouud Injection Control Prograat.
6dL Water Icvel below ground sdrrfacc: 4 00 1636 Mail Service Center.Raleigh.NC 27699-1636
Ik.For Water,Supply&ighetinn Wells: in addidoo to swd og the form to
tie:Over ear+lug Ieato(if Wwwv): 8.5 MCI the uddrewes) aW,e. also submit one cop) of this fora wi[luit ?n dame of
completion of well absadaametn to the count% health dtpartment of the oo8aty
where abandoned,
tit.tarter casinghubbt)t letrgt6 fifkitstrtt): {A.)
6P,Screen length(if kwows):10 00
Pam OW-10 Noah Camlim Depantwri of F.nriroament and Wound RcsmKcs-Dj%ision of Water Resouxes Rn*W AVM 2013

WELL ABANDON MLt'NT RUC:URD For Internal Use ONLY:
1.Well Contractor Informattiion: WELL ARALN"NMEN'1'DETAILS
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 1 Cf W-30 is needed. Indicate TOTAL NUMBER of
2-4 3 A wells abandoned: j N
NC Weil Contractor Certification Numbs 7b.Approximate volume of water remaining in rre11(s): (gal.)
Ft-�,-i G is ���� �-�( ono �, FOR WATER SUPPLY VVEI,I S UNLY:
company Name T
` 7e.1'ypr of disinfectant used: �
2.Well Construction Permit#: 1 4 V L�
List all applicable well construction pamita(i.e.U1C,Coanty,State,Yarfm",etc)ii noutt � G�
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
tDAgticultural I7MunicipaUPablic O Neat Cement Grout 1x(Bmtonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ll3Csidential Water Supply(single) O Sand Cement Grout 0 Dry Clay
alndustriallcommereial DResidemial Water Supply(shared) O Conereto Grout C7 Drill Cuttings
❑Irri atiott O Specialty Grout O Gravel
Non-Water Supply Well: Cf Bentonite Slurry 0 lather(explain under 7g)
OMonitoring ORecovery
Injeellon Well: 7f.For each material selected above,provide amount of materials used:
OAquifer Recharge OCrroundwater Remediation (5c)ti 6 S
OAquifer Storage and Recovery OSaliaity Barrier
OAquifer Test LlStonnwater Drainage
Olarperimental Technology OSubsidence Control
7g.Provide s brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTmmr II
OGeothermal(Tice oof Return) QOther(explain under 7 S G o oL)
4.Date well(,)abandoned: O 23�2 C
5a.Well location:
VI
FacitityAMW flame Facility WN(ifapplinlik) 8.Certllloalion o
son Dow Rd C km-Lotc N ci z$zo
Physical Address.City,and Tip 3" of edifted Well Con trac.or or Well Owner Date
/VleC'�'A Q,V%L0 J•q 03 a32-Q3 By signing this fo»n. I hereby certify that the wells)was(were)abandoned in
County �— Parcel Identification No.(PIN) accordance wilk 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record luis been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one Wong is sufficient) 9.Site diagram or additional well details:
N 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 "U OF WELLISI BEIi`(9 AITANDONED SUMMIAL INR'I•r4UCTIONS
Attach well construction mcord(s)ifavailable. Ibrmultipie irVeaion ornon-watersupply weNs
ONLY with the same constructk✓abcoWonment,you can submit nee form.
10m. );or All �„Vslls: Submit Otis form within 30 days of completion of well
6a.Well ID#: A abandoometrt to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: -7 2 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.&r Inlection Wells: In addition to sending the form to the address in 10a
6c-Borehole diameter: (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 (ft) Division of Water Resources,Underground Injection Control Program,
d 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer easing length(if known):/�J M.) 10c.For M(MIr Sunnfv&InissJoe Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
� n of well abandonment to the axtnty health department of the county where
Al6f.Inner casing/tubing length Of known):-� 1/74 (n.) abandoned'
6g.Screen length(if known): /V lTj L (ft.)